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關於脊醫治療及頸痛的醫學研究
J Manipulative Physiol Ther. 2010 Oct;33(8):612-7.

Validity of weekly recall ratings of average pain intensity in neck pain patients.
Bolton JE, Humphreys BK, van Hedel HJ.

Anglo-European College of Chiropractic, Bournemouth, UK. [email protected]

Abstract
OBJECTIVE: Ratings of usual pain over a period of 1 week are commonly used to rate a patient's usual level of pain intensity. This study investigated the validity of weekly recall pain ratings and biasing effects of pain levels on these ratings.

METHODS: Seventy-eight patients presenting to a chiropractic outpatient clinic with nonspecific neck pain completed a 7-day diary rating their pain 4 times each day on an 11-point numerical rating scale. From these 28 ratings, the patients' "actual average" pain was computed. On day 8, patients were asked to rate their current pain, as well as recall their pain "on average," at its "worst," and at its "least" over the previous week.

RESULTS: Recall of average pain over the previous week was shown to be a valid measure using ratings of actual pain as the criterion standard (Pearson r = 0.95). The error between actual and recall readings was random and consistent across all levels of actual pain. Patients were also able to accurately recall their pain at its worst (r = 0.93) and at its least (r = 0.92) over the preceding week. In regression analyses, there were no appreciable biasing effects on the recall of average pain of either current pain at the time of recall, or of pain at its worst or at its least during the recall period.

CONCLUSION: These results suggest that recall ratings of pain intensity may be valid for use in clinical research and practice on patients with nonspecific neck pain.

Chiropr Osteopat. 2010 Jul 9;18:20.

Relative effectiveness and adverse effects of cervical manipulation, mobilisation and the activator instrument in patients with sub-acute non-specific neck pain: results from a stopped randomised trial.
Gemmell H, Miller P.

Principal Lecturer Chiropractic Sciences, Department of Academic Affairs Anglo-European College of Chiropractic Bournemouth, Dorset, UK. [email protected]

Abstract
BACKGROUND: Neck pain of a mechanical nature is a common complaint seen by practitioners of manual medicine, who use a multitude of methods to treat the condition. It is not known, however, if any of these methods are superior in treatment effectiveness. This trial was stopped due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, (2) to report on the data obtained from subjects who completed the study, (3) to discuss the problems we encountered in conducting this study.

METHODS: A pragmatic randomised clinical trial was undertaken. Patients who met eligibility criteria were randomised into three groups. One group was treated using specific segmental high velocity low amplitude manipulation (diversified), another by specific segmental mobilisation, and a third group by the Activator instrument. All three groups were also treated for any myofascial distortions and given appropriate exercises and advice. Participants were treated six times over a three-week period or until they reported being pain free. The primary outcome measure for the study was Patient Global Impression of Change (PGIC); secondary outcome measures included the Short-Form Health Survey (SF-36v2), the neck Bournemouth Questionnaire, and the numerical rating scale for pain intensity. Participants also kept a diary of any pain medication taken and noted any perceived adverse effects of treatment. Outcomes were measured at four points: end of treatment, and 3, 6, and 12 months thereafter.

RESULTS: Between January 2007 and March 2008, 123 patients were assessed for eligibility, of these 47 were considered eligible, of which 16 were allocated to manipulation, 16 to the Activator instrument and 15 to the mobilisation group. Comparison between the groups on the PGIC adjusted for baseline covariants did not show a significant difference for any of the endpoints. Within group analyses for change from baseline to the 12-month follow up for secondary outcomes were significant for all groups on the Bournemouth Questionnaire and for pain, while the mobilisation group had a significant improvement on the PCS and MCS subscales of the SF-36v2. Finally, there were no moderate, severe, or long-lasting adverse effects reported by any participant in any group.

CONCLUSIONS: Although the small sample size must be taken into consideration, it appears that all three methods of treating mechanical neck pain had a long-term benefit for subacute neck pain, without moderate or serious adverse events associated with any of the treatment methods. There were difficulties in recruiting subjects to this trial. This pragmatic trial should be repeated with a larger sample size.

J Can Chiropr Assoc. 2010 Jun;54(2):118-31.

Outcome measures and their everyday use in chiropractic practice.
Hinton PM, McLeod R, Broker B, Maclellan CE.

Private practice, Prince Albert, SK. Tel: 306 922-7028. Email: [email protected]

Abstract
OBJECTIVES: To describe the extent to which chiropractors utilize standardized outcome and various clinical measures to systematically document patients' baseline health status and responses to treatment, with particular consideration being given towards quantifiable outcome instruments.

STUDY DESIGN: Cross-sectional mailed survey.

PARTICIPANTS: Registered chiropractors in the province of Saskatchewan.

METHODS: A survey was mailed to all registrants of the Chiropractors' Association of Saskatchewan. Respondents graded their frequency of using various standardized pencil-and-paper instruments and functional chiropractic, orthopaedic and neurological tests in the contexts of both the initial intake assessment ('always,' 'commonly,' 'occasionally,' or 'never') and the course of subsequent treatment (after 'each visit,' after '9-12 visits,' 'annually,' when patient 'not responding,' on 'dismissal/discharge,' 'never' or for some 'other' reason). Data were tabulated for all item and response category combinations as frequencies and percentages using the total sample size as the denominator.

RESULTS: Of 164 registered chiropractors, 62 (38%) returned a completed questionnaire. A pain diagram was the most commonly used subjective outcome measure and was administered routinely (either "always" or "commonly") by 75% of respondents, at either the initial consultation or during a subsequent visit. Numerical rating and visual analogue scales were less popular (routinely used by 59% and 42% respectively). The majority of respondents (80%) seldom ("occasionally" or "never") used spine pain-specific disability indices such as the Low Back Revised Oswestry, Neck Disability Index or the Roland-Morris Questionnaire. As well, they did not use standardized psychosocial instruments such as the Beck Depression Index, or general health assessment measures such as the SF-36 or SF-12 questionnaire. Neurological testing was the most commonly used objective outcome measure. Most respondents (84% to 95%) indicated that they continually monitored neurological status through dermatomal, manual muscle strength and deep tendon reflex testing. Ranges of motion were routinely measured by 95% of respondents, usually visually (96%) rather than goniometrically or by some other specialized device (7%).

CONCLUSIONS: Our findings suggest that the majority of chiropractors do not use psychosocial questionnaires or condition-specific disability indices to document baseline or subsequent changes in health status. Chiropractors are more likely to rely on medical history taking and pain drawings during an initial intake assessment, as well as neurological and visually estimated range of motion testing during both initial intake and subsequent treatment visits.

Work. 2010;35(3):369-94.

A systematic review of chiropractic management of adults with Whiplash-Associated Disorders: recommendations for advancing evidence-based practice and research.
Shaw L, Descarreaux M, Bryans R, Duranleau M, Marcoux H, Potter B, Ruegg R, Watkin R, White E.

Faculty of Health Sciences, School of Occupational Therapy, University of Western Ontario, London, ON, Canada.

Abstract
The literature relevant to the treatment of Whiplash-Associated Disorders (WAD) is extensive and heterogeneous.

METHODS: A Participatory Action Research (PAR) approach was used to engage a chiropractic community of practice and stakeholders in a systematic review to address a general question: 'Does chiropractic management of WAD clients have an effect on improving health status?' A systematic review of the empirical studies relevant to WAD interventions was conducted followed by a review of the evidence.

RESULTS: The initial search identified 1,155 articles. Ninety-two of the articles were retrieved, and 27 articles consistent with specific criteria of WAD intervention were analyzed in-depth. The best evidence supporting the chiropractic management of clients with WAD is reported. Further review identified ways to overcome gaps needed to inform clinical practice and culminated in the development of a proposed care model: the WAD-Plus Model.

CONCLUSIONS: There is a baseline of evidence that suggests chiropractic care improves cervical range of motion (cROM) and pain in the management of WAD. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at this time. The WAD-Plus Model has implications for use by chiropractors and interdisciplinary professionals in the assessment and management of acute, subacute and chronic pain due to WAD. Furthermore, the WAD-Plus Model can be used in the future study of interventions and outcomes to advance evidence-based care in the management of WAD.

J Manipulative Physiol Ther. 2010 Mar-Apr;33(3):178-88.

Altered central integration of dual somatosensory input after cervical spine manipulation.
Taylor HH, Murphy B.

Director of Research, New Zealand College of Chiropractic, Auckland, New Zealand. heidi.tayl[email protected]

Abstract
OBJECTIVE: The aim of the current study was to investigate changes in the intrinsic inhibitory interactions within the somatosensory system subsequent to a session of spinal manipulation of dysfunctional cervical joints.

METHOD: Dual peripheral nerve stimulation somatosensory evoked potential (SEP) ratio technique was used in 13 subjects with a history of reoccurring neck stiffness and/or neck pain but no acute symptoms at the time of the study. Somatosensory evoked potentials were recorded after median and ulnar nerve stimulation at the wrist (1 millisecond square wave pulse, 2.47 Hz, 1 x motor threshold). The SEP ratios were calculated for the N9, N11, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar (MU) stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median (M) and ulnar (U) nerves.

RESULTS: There was a significant decrease in the MU/M + U ratio for the cortical P22-N30 SEP component after chiropractic manipulation of the cervical spine. The P22-N30 cortical ratio change appears to be due to an increased ability to suppress the dual input as there was also a significant decrease in the amplitude of the MU recordings for the same cortical SEP peak (P22-N30) after the manipulations. No changes were observed after a control intervention.

CONCLUSION: This study suggests that cervical spine manipulation may alter cortical integration of dual somatosensory input. These findings may help to elucidate the mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation treatment.

J Manipulative Physiol Ther. 2010 Mar-Apr;33(3):168-77.

The effect of spinal manipulation on the efficacy of a rehabilitation protocol for patients with chronic neck pain: a pilot study.
Murphy B, Taylor HH, Marshall P.

Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada. [email protected]

Abstract
OBJECTIVE: This pilot study sought to (1) determine whether a 4-week period of chiropractic care improved the ability of chronic neck pain patients to respond to an 8-week period of exercise rehabilitation and (2) determine effect sizes to use in sample size calculations for future studies.

METHODS: Twenty male and female participants (age, 43 +/- 12 years; body mass index, 27 +/- 4.5 [mean +/- SD]) with chronic nonspecific neck pain were randomized into either a chiropractic care combined with exercise or an exercise only group. Group 1 received 4 weeks of chiropractic care, and group 2 waited 4 weeks before both groups participated in an 8-week exercise intervention. The following outcome measures were assessed in week 1 (baseline), week 4, and at week 12: Neck Disability Index (NDI); Visual Analogue Scale (VAS), both now and worst; neck flexion-relaxation response; and feed-forward activation (FFA) times. A repeated-measures analysis of variance was used to evaluate the changes in the NDI and VAS over time. Effect sizes were calculated for changes in neuromuscular parameters.

RESULTS: There were significant decreases in the NDI score (P < .001) and VAS in (P < .005) in both groups with no significant differences between the groups. Effect sizes (ESs) were as follows: NDI (.293); VAS now (.175); VAS worst (.392); flexion-relaxation (.636); FFA times: sternocleidomastoid (.1321), anterior scalene (.195). This lead to sample size estimates as follows: flexion-relaxation response, 64 subjects per group; NDI, 145 subjects per group; VAS, 166 subjects per group.

CONCLUSIONS: Chiropractic care combined with exercise and exercise alone are both effective at reducing functional disability and pain in chronic nonspecific neck pain patients. Future studies will need at least 64 subjects per group to determine if there are differences between the groups and if these differences are attributable to changes in neuromuscular measures.

Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004249.

Manipulation or mobilisation for neck pain.
Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brnfort G, Hoving JL.

School of Rehabilitation Science & Dept Clinical Epidemiology and Biostatistics, McMaster University, 1400 Main Street West, Hamilton, Ontario, Canada, L8S 1C7.

Update of:

Cochrane Database Syst Rev. 2004;(1):CD004249.

Abstract
BACKGROUND: Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain.

OBJECTIVES: To assess if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life, and global perceived effect in adults with acute/subacute/chronic neck pain with or without cervicogenic headache or radicular findings.

SEARCH STRATEGY: CENTRAL (The Cochrane Library 2009, issue 3) and MEDLINE, EMBASE, Manual Alternative and Natural Therapy, CINAHL, and Index to Chiropractic Literature were updated to July 2009.

SELECTION CRITERIA: Randomised controlled trials on manipulation or mobilisation.

DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, abstracted data, and assessed risk of bias. Pooled relative risk and standardised mean differences (SMD) were calculated.

MAIN RESULTS: We included 27 trials (1522 participants).Cervical Manipulation for subacute/chronic neck pain : Moderate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence showed manipulation alone compared to a control may provide short- term relief following one to four sessions (SMD pooled -0.90 (95%CI: -1.78 to -0.02)) and that nine or 12 sessions were superior to three for pain and disability in cervicogenic headache. Optimal technique and dose need to be determined.Thoracic Manipulation for acute/chronic neck pain : Low quality evidence supported thoracic manipulation as an additional therapy for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and favoured a single session of thoracic manipulation for immediate pain reduction compared to placebo for chronic neck pain (NNT 5, 29% treatment advantage).Mobilisation for subacute/chronic neck pain: In addition to the evidence noted above, low quality evidence for subacute and chronic neck pain indicated that 1) a combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function; 2) there was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function; and 3) neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment. Certain mobilisation techniques were superior.

AUTHORS' CONCLUSIONS: Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

J Manipulative Physiol Ther. 2009 Nov-Dec;32(9):765-71.

Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases.
Aspegren D, Enebo BA, Miller M, White L, Akuthota V, Hyde TE, Cox JM.

Department of Rehabilitation, University of Colorado School of Medicine, Lakewood, CO 80215, USA. [email protected]

Abstract
OBJECTIVE: The purpose of this study is to report on integrative care for the treatment of injured workers with neck or back pain referred to a doctor of chiropractic from a medical or osteopathic provider.

METHODS: This retrospective case series study evaluated data on 100 patients referred for chiropractic care of work-related spinal injuries involving workers' compensation claims. Deidentified data included age, sex, visual analog scale scores for pain, pre- and posttreatment Functional Rating Index (FRI) scores, and subjective response to chiropractic care. Based on date of injury to first chiropractic treatment, patients were subdivided as acute, subacute, or chronic injured workers. Cases were analyzed for differences in pretreatment FRI scores, posttreatment FRI scores, FRI change scores (posttreatment FRI minus pretreatment FRI score), and subjective percentage improvement using a 1-way analysis of variance. Treatment included manual therapy techniques and exercise.

RESULTS: Injured workers with either an acute or subacute injury had significantly lower posttreatment FRI scores compared with individuals with a chronic injury. The FRI change scores were significantly greater in the acute group compared with either the subacute or chronic injured workers. Workers in all categories showed improved posttreatment tolerance for work-related activities and significantly lower posttreatment subjective pain scores.

CONCLUSIONS: The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional scores and subjective response was noted in all 3 time-based phases of patient status (acute, subacute, and chronic).

J Manipulative Physiol Ther. 2000 Jun;23(5):307-11.

Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis.
McMorland G, Suter E.

Hillhurst Chiropractic Office, Calgary, Canada.

Abstract
BACKGROUND: Evidence suggests that spinal manipulation is an effective treatment for mechanical neck and low-back pain (LBP). Treatment efficacy is important to establish for these symptoms because combined they account for a considerable amount of disability and substantial associated direct and indirect costs to society.

OBJECTIVE: The purpose of this study was to examine the outcome of patients undergoing chiropractic treatment for mechanical neck or LBP. Design and Setting: A retrospective, outcome-based analysis was done for patients seeking care at a private chiropractic practice over a 1-year period. A total of 512 files were reviewed, with 119 patients selected for inclusion. Patients were included if their chief symptom was uncomplicated mechanical neck or LBP. Diagnoses included cervical, lumbar, or sacroiliac joint sprain/strain (International Code of Diagnostics version 9 [ICD-9] code: 847.1, 847.3, 846.1, respectively), discogenic LBP (ICD-9: 722.1), and headaches (ICD-9: 784.0) because many patients with neck pain presented with concomitant headaches. Disability and pain were measured with the modified Oswestry scale (for the patients with LBP), Neck Disability Index, and an 11-box visual analogue pain scale before and after treatment. Treatment consisted of spinal manipulation, various soft-tissue techniques, home-care instructions, and ergonomic and return-to-activity advice, including rehabilitative exercises. Patients received an average of 12 treatments over a 4-week period. Statistical analysis was performed on pretreatment and posttreatment values for both disability and pain. Stratification was based on duration (acute/subacute, chronic, acute exacerbation of a chronic condition) and severity (mild, moderate, or severe) of symptoms.

RESULTS: Statistically significant reductions in disability and pain scores were achieved in all groups. An average 52.5% and 52.9% reduction in pain and disability, respectively, was achieved in the low-back group. The chronic LBP group realized a less statistically significant reduction of pain and disability (19.7% and 19.8%, respectively) than the acute/subacute (66.8% and 62.5%) or the chronic/recurrent group (56. 5% and 63.4%). The differences were statistically significant. Patients with neck pain had an average 53.8% and 48.4% reduction in their pain and disability, respectively. Patients with concomitant neck pain and headaches had statistically significant higher pretreatment and posttreatment disability and pain scores than those with only neck pain. There was no statistically significant difference in outcomes between groups stratified according to pain intensity.

CONCLUSIONS: Patients attending a private chiropractic clinic for treatment of mechanical neck pain or LBP had statistically significant reductions in their pain-related disability after treatment. These results indicate that chiropractic manipulation is beneficial for the treatment of mechanical neck pain and LBP. However, care must be taken when drawing conclusions from these outcomes. The study design does not account for the natural history of low back- or neck pain-related disability and therefore does not allow for claims of treatment efficacy. In addition, it has been suggested that patients presenting to medical doctors with these symptoms have significant overlying comorbidity when compared with patients presenting to a chiropractor.

J Chiropr Med. 2009 Dec;8(4):156-64.

Effects of chiropractic care on dizziness, neck pain, and balance: a single-group, preexperimental, feasibility study.
Strunk RG, Hawk C.

Assistant Professor, Clinical Sciences/Research, Cleveland Chiropractic College, Overland Park, KS.

Abstract
OBJECTIVE: This feasibility study was conducted to further the development of a line of investigation into the potential effects of spinal manipulation/manual therapy on cervicogenic dizziness, balance, and neck pain in adults.

METHODS: A single-group, preexperimental, feasibility study was conducted at a chiropractic college health center and a senior fitness center with a target sample size of 20 patients (40 years or older). Patients were treated by either a clinician or a chiropractic student intern for 8 weeks. The Dizziness Handicap Inventory was the primary outcome measurement, with the Short Form Berg Balance Scale (SF-BBS) and the Neck Disability Index used as secondary outcome measurements.

RESULTS: Twenty-seven patients were recruited over a period of 13 months. Twenty-one patients enrolled in the study; but because of 2 dropouts, 19 patients completed the treatment. A median Dizziness Handicap Inventory change score of +7 points was calculated for those dizziness patients, with 3 patients improving by at least 18 points, indicating a clinically meaningful change. Seven of the 15 patients who performed the SF-BBS attained at least a 4-point improvement with an effect size of 1.2. A median Neck Disability Index change score of +1 was calculated for those patients with neck pain. Twelve minor adverse reactions were reported by 8 patients, with 3 of those reactions lasting longer than 24 hours.

CONCLUSION: A large effect size was calculated for the SF-BBS. Most patients demonstrated improved balance, and some showed reduced dizziness and neck pain. Involving interns in care proved feasible. Further studies with comparison groups and larger samples are needed to explore the promising results of this study before any cause and effect relationship can be determined.

J Manipulative Physiol Ther. 2009 Jul-Aug;32(6):431-7.

Chiropractic care for older adults: effects on balance, dizziness, and chronic pain.
Hawk C, Cambron J.

Cleveland Chiropractic College, Kansas City, MO, USA. [email protected]

Abstract
OBJECTIVE: This study is part of an avenue of research exploring the effect of chiropractic care on balance in older adults. The purpose of this study was to (1) assess the use of the 7-item version of the Berg Balance Scale, (2) explore possible effects of an 8-week course of chiropractic care on balance as measured by the 7-item Short-Form Berg Balance Scale (SF-BBS) in adults 65 years or older with impaired balance, and (3) collect preliminary information on the possible relationships of dizziness and/or chronic pain to poor balance.

METHODS: This was a single-group, pretest/posttest design intervention study. Patients 65 years and older who could stand on one leg for less than 5 seconds were eligible. They received pragmatic chiropractic care for 16 visits for an 8-week period. Outcomes were assessed at baseline, visit 8 and visit 16 in terms of balance SF-BBS, dizziness (Dizziness Handicap Inventory [DHI]), chronic pain (Pain Disability Index), and depression (Geriatric Depression Scale).

RESULTS: Sixteen patients were enrolled; 14 completed the study. There was one mild and transient adverse effect, muscle soreness, which self-resolved. One patient was depressed, and his Geriatric Depression Scale score improved significantly during the study. Of the 6 patients with significant dizziness at baseline, 3 had scores of 0 (no dizziness) on the DHI at visit 16. Patients with dizziness tended to have greater chronic pain and show greater reductions in that pain than nondizzy patients. No clinically important effects on balance as measured by the SF-BBS were apparent for the group as a whole, although 3 individual patients improved by 4 to 6 points.

CONCLUSION: The Short-Form Berg Balance Scale (SF-BBS) did not show a great deal of clinical responsiveness in this study population. The outcome measures used for chronic pain (Pain Disability Index) and dizziness (DHI) appear to be appropriate for assessing patients in future larger studies for longer periods.

J Can Chiropr Assoc. 2009 Aug;53(3):173-85.

Neck pain and disability outcomes following chiropractic upper cervical care: a retrospective case series.
Rochester RP.

Chiropractic Spine Center of North Georgia, Inc., 475 S. Washington Street, Suite C, Clarkesville, GA 30523. Society of Chiropractic Orthospinology, Inc. (Non-profit organization) Board of Directors, Co-Author of the text: Orthospinology Procedures, An Evidence-Based Approach to Spinal Care. Philadelphia: Lippincott Williams & Wilkins, 2007.

Abstract
OBJECTIVE: To investigate the use of an upper cervical low-force (UCLF) chiropractic procedure, based on a vertebral alignment model, in the management of neck pain and disability by assessing the impact on valid patient outcome measures.

DESIGN: A retrospective case series.

METHODS: Consecutive patient files at a private chiropractic practice over a 1-year period were reviewed for inclusion. Data for the first visit, pre- and post-adjustment atlas alignment radiographic measurements, baseline and 2-weeks NDI (100 point) and verbal NRS (11 point) were recorded. The data were analyzed in their entirety and by groups comparing <30% vs. >30% post adjustment atlas alignment changes.

RESULTS: Statistically significant clinically meaningful improvements in neck pain NRS (P < 0.01) and disability NDI (P < 0.01) after an average of 13.6 days of specific chiropractic care including 5.7 office visits and 2.7 upper cervical adjustments were demonstrated. There were no serious adverse events. Cases with the post-adjustment skull/atlas alignment measurement (atlas laterality) that were changed more than 30% on the first visit toward the orthogonal alignment predicted a statistically and clinically significant better outcome for NDI in 2 weeks.

CONCLUSIONS: UCLF chiropractic instrument adjustments utilizing a vertebral alignment model are promising for the management of patients with neck pain based on assessment using valid outcome measures.

J Manipulative Physiol Ther. 2009 Jul-Aug;32(6):414-22.

Characterization of health status and modifiable risk behavior among United States adults using chiropractic care as compared with general medical care.
Ndetan HT, Bae S, Evans MW Jr, Rupert RL, Singh KP.

Parker College Research Institute, Dallas, Tex 75229, USA. [email protected]

Abstract
OBJECTIVE: The causes of death in the United States have moved from infectious to chronic diseases with modifiable behavioral risk factors. Simultaneously, there has been a paradigm shift in health care provisions with increased emphases on prevention and health promotion. Use of professional complementary and alternative medicine, such as chiropractic care, has increased. The purpose of this study was to characterize typical conditions, modifiable risk behaviors, and perceived changes in overall general health of patients seeing chiropractors as compared with general medical doctors in the United States.

METHODS: Secondary analyses of the National Health Interview Survey 2005 adult sample (n = 31,248) were performed. Multiple logistic regression models were applied to assess associations of health conditions/risk behaviors of patients with the doctors (chiropractors vs medical doctors) they saw within the past 12 months.

RESULTS: Respondents who saw/talked to chiropractors were 9.3%. Among these, 21.4% did not see a medical doctor. Comparing chiropractor-only with medical doctor-only patients, we found no significant difference in smoking/alcohol consumption status, but chiropractor-only patients were more likely to be physically active (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8) and less likely to be obese (OR, 0.7; 95% CI, 0.6-0.9). Respondents reporting acute neck (OR, 2.7; 95% CI, 2.2-3.2) and low back pain (OR, 2.4; 95% CI, 2.0-2.8) were more likely to have seen a chiropractor.

CONCLUSIONS: Based on these analyses, Americans seem to be using chiropractic care for acute neck and low back pain more so than for other health conditions. However, there is no marked difference in their overall health promotion habits and changes in overall general health based on health care provider types.

J Chiropr Med. 2009 Sep;8(3):131-6.

Chiropractic care of a 6-year-old girl with neck pain; headaches; hand, leg, and foot pain; and other nonmusculoskeletal symptoms.
Roberts J, Wolfe T.

HealthQuest Chiropractic, Farmington, ME 04938.

Abstract
OBJECTIVE: The purpose of this case report is to describe the response to chiropractic care of a pediatric patient with complaints of neck pain; headaches; and hand, leg, and foot pain after head trauma and the reports of changes in the patient's history of chronic fatigue, vomiting, and coughing.

CLINICAL FEATURES: A 6-year-old girl was pushed into a playground slide, hitting her head and resulting in acute complaints of her "neck and brain hurting" and hand, foot, and occasional leg pain. In addition, the patient had a several-year history of unexplained fatigue, vomiting, and coughing spells. She had a neck pain disability index of 17.8%; left lateral and rotational head tilt; cervical antalgic lean; loss of cervical range of motion; anterior cervical translation; and spasm, tenderness, trigger points, and edema along the cervical and thoracic spine.

INTERVENTION AND OUTCOME: The patient was cared for using Activator Methods protocol. After the fifth treatment, all the patient's symptoms dissipated, with a complete return to normal activity and spinal stability after 9 treatments. At 19 weeks, her spine continued to be asymptomatic; and her neck disability index was 0%.

CONCLUSION: This case demonstrated that the Activator Method of chiropractic care had a beneficial effect for this pediatric patient.

J Man Manip Ther. 2008;16(2):E42-52.

Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized controlled trials of a single session.
Vernon H, Humphreys BK.

Professor, Division of Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada.

Abstract
We report a systematic analysis of group change scores of subjects with chronic neck pain not due to whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy. A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted. Trials that scored above 60% on the PEDro Scale were included. Change scores were analyzed for absolute, percentage change and effect size (ES) whenever possible. Nine trials were identified: 6 for spinal manipulation, 4 for spinal mobilization or non-manipulative manual therapy (2 overlapping trials), and 1 trial using ischemic compression. No trials were identified for massage therapy or manual traction. Four manipulation trials (five groups) reported mean immediate changes in 100-mm VAS of -18.94 (9.28) mm. ES for these changes ranged from .33 to 2.3. Two mobilization trials reported immediate VAS changes of -11.5 and -4 mm (ES of .36 and .22, respectively); one trial reported no difference in immediate pain scores versus sham mobilization. The ischemic compression study showed statistically significant immediate decreases in 100-mm pain VAS (average = -14.6 mm). There is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a single session of spinal manipulation. The evidence for mobilization is less substantial, with fewer studies reporting smaller immediate changes. There is insufficient evidence for ischemic compression to draw conclusions. There is no evidence for a single session of massage or manual traction for chronic neck pain.

Chiropr Osteopat. 2008 Oct 30;16:12.

Spinal manipulative therapy versus Graston Technique in the treatment of non-specific thoracic spine pain: design of a randomised controlled trial.
Crothers A, Walker B, French SD.

School of Chiropractic and Sports Science, Murdoch University, Murdoch, Western Australia, Australia. [email protected]

Abstract
BACKGROUND: The one year prevalence of thoracic back pain has been estimated as 17% compared to 64% for neck pain and 67% for low back pain. At present only one randomised controlled trial has been performed assessing the efficacy of spinal manipulative therapy (SMT) for thoracic spine pain. In addition no high quality trials have been performed to test the efficacy and effectiveness of Graston Technique (GT), a soft tissue massage therapy using hand-held stainless steel instruments. The objective of this trial is to determine the efficacy of SMT and GT compared to a placebo for the treatment of non specific thoracic spine pain. METHODS: Eighty four eligible people with non specific thoracic pain mid back pain of six weeks or more will be randomised to one of three groups, either SMT, GT, or a placebo (de-tuned ultrasound). Each group will receive up to 10 supervised treatment sessions at the Murdoch University Chiropractic student clinic over a 4-week period. Treatment outcomes will be measured at baseline, one week after their first treatment, upon completion of the 4-week intervention period and at three, six and twelve months post randomisation. Outcome measures will include the Oswestry Back Pain Disability Index and the Visual Analogue Scale (VAS). Intention to treat analysis will be utilised in the statistical analysis of any group treatment effects.

J Can Chiropr Assoc. 2008 Aug;52(3):161-7.

A literature review of neck pain associated with computer use: public health implications.
Green BN.

Chiropractic Division, Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, CA, USA. [email protected]

Abstract
Prolonged use of computers during daily work activities and recreation is often cited as a cause of neck pain. This review of the literature identifies public health aspects of neck pain as associated with computer use. While some retrospective studies support the hypothesis that frequent computer operation is associated with neck pain, few prospective studies reveal causal relationships. Many risk factors are identified in the literature. Primary prevention strategies have largely been confined to addressing environmental exposure to ergonomic risk factors, since to date, no clear cause for this work-related neck pain has been acknowledged. Future research should include identifying causes of work related neck pain so that appropriate primary prevention strategies may be developed and to make policy recommendations pertaining to prevention.

J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):461-4.

Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?
Rubinstein SM.

Institute for Research in Extramural Medicine, EMGO-Institute, VU University Medical Center, 1081 BT Amsterdam, The Netherlands. [email protected]

Abstract
This synopsis provides an overview of the benign and serious risks associated with chiropractic care for subjects with neck or low-back pain. Most adverse events associated with spinal manipulation are benign and self-limiting. The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.

Spine (Phila Pa 1976). 2008 Jun 1;33(13):1451-8.

Predictors of a favorable outcome in patients treated by chiropractors for neck pain.
Rubinstein SM, Knol DL, Leboeuf-Yde C, de Koekkoek TE, Pfeifle CE, van Tulder MW.

Institute for Research in Extramural Medicine (EMGO-Institute), VU University Medical Center, Amsterdam, The Netherlands. [email protected]

Erratum in:

Spine. 2008 Oct 15;33(22):2482.

Abstract
STUDY DESIGN: Prospective, multicenter, cohort study.

OBJECTIVE: To examine which clinical and sociodemographic baseline variables can predict a favorable outcome in subjects with neck pain treated by chiropractors.

SUMMARY OF BACKGROUND DATA: Relatively little is known on predictors of neck pain, particularly for those subjects undergoing chiropractic care. No previous study has examined predictors of outcome for subjects with neck pain by modeling the trajectories of subjects in a longitudinal design.

METHODS: All new, consecutive patients, between 18 and 65 years of age with neck pain of any duration, who had not undergone chiropractic or manual therapy in the prior 3 months, were recruited. Questionnaires were administered at the first 3 visits, and at 3 and 12 months. In all, 29 putative prognostic baseline variables were evaluated. Multivariate multilevel longitudinal regression analyses were conducted using neck pain, neck disability, and perceived recovery as outcomes.

RESULTS: In total, 529 patients fulfilled the inclusion criteria. The response rate at 12-months was 92%. In the multivariate analyses, 14 (48%) of the prognostic variables examined were retained in at least one of the models. Shorter duration of neck pain at the first visit was the only variable retained in all 3 final regression models. The following were predictive of a favorable outcome for any 2 of the 3 outcome measures examined: intermittent neck pain, those not on sick-leave or receiving workers compensation at baseline, a higher level of education, less tiredness, higher expectations that the treatment would be beneficial, lack of morning pain, and worse perceived general health.

CONCLUSION: On the basis of the patient's history, the clinician can identify a number of determinants, which are predictive of a favorable outcome. Shorter duration of neck pain at the first visit was the only variable consistently found to be predictive of a favorable outcome for all 3 outcome measures examined.

J Manipulative Physiol Ther. 2008 Mar;31(3):172-83.

Predictors for immediate and global responses to chiropractic manipulation of the cervical spine.
Thiel HW, Bolton JE.

Anglo-European College of Chiropractic, Bournemouth, BH5 2DF England, UK.

Abstract
OBJECTIVE: Patients with nonspecific musculoskeletal disorders may vary in their response to treatment. This study set out to identify the predictors for either improvement or worsening in symptoms for which cervical spine manipulation is indicated.

METHOD: A large prospective study recorded details on patients, their presenting symptoms, and type of treatment. At the end of the consultation, any immediate improvement or worsening in presenting symptoms was noted. At the follow-up visit, information was collected on the patients' self-reported improvement.

RESULTS: Data were collected from 28,807 treatment consultations (in 19,722 patients) and 13,873 follow-up treatments. The presenting symptoms of "neck pain," "shoulder, arm pain," "reduced neck, shoulder, arm movement, stiffness," "headache," "upper, mid back pain," and "none or one presenting symptom" emerged in the final model as significant predictors for an immediate improvement. The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to approximately 95%. With regard to immediate worsening, "neck pain," "shoulder, arm pain, "headache," "numbness, tingling upper limbs," "upper, mid back pain," and "fainting, dizziness, light-headedness" emerged as predictors; and the presence of any 4 of these raised the probability for immediate worsening from 4.4% to approximately 12%. For global improvement, only 2 predictors were identified; but these did not enhance the postprediction probability.

CONCLUSIONS: This study is the first attempt to identify variables that can predict immediate outcomes in terms of improvement and worsening of presenting symptoms, and global improvement, after cervical spine manipulation. The predictor variables were strongest for immediate improvement.

J Manipulative Physiol Ther. 2008 Feb;31(2):115-26.

Altered sensorimotor integration with cervical spine manipulation.
Taylor HH, Murphy B.

New Zealand College of Chiropractic, Auckland, New Zealand. [email protected]

Abstract
OBJECTIVE: This study investigates changes in the intrinsic inhibitory and facilitatory interactions within the sensorimotor cortex subsequent to a single session of cervical spine manipulation using single- and paired-pulse transcranial magnetic stimulation protocols.

METHOD: Twelve subjects with a history of reoccurring neck pain participated in this study. Short interval intracortical inhibition, short interval intracortical facilitation (SICF), motor evoked potentials, and cortical silent periods (CSPs) were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single- and paired-pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were recorded after median nerve stimulation at the wrist.

RESULTS: After cervical manipulations, there was an increase in SICF, a decrease in short interval intracortical inhibition, and a shortening of the CSP in abductor pollicis brevis. The opposite effect was observed in extensor indices proprios, with a decrease in SICF and a lengthening of the CSP. No motor evoked potentials or F wave response alterations were observed, and no changes were observed after the control condition.

CONCLUSION: Spinal manipulation of dysfunctional cervical joints may alter specific central corticomotor facilitatory and inhibitory neural processing and cortical motor control of 2 upper limb muscles in a muscle-specific manner. This suggests that spinal manipulation may alter sensorimotor integration. These findings may help elucidate mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation.

J Chiropr Med. 2008 Mar;7(1):17-23.

Resolution of cervical radiculopathy in a woman after chiropractic manipulation.
Whalen WM.

Clinical Director, Whalen Chiropractic, Santee, CA 92071.

Abstract
OBJECTIVE: To describe a case regarding a woman with 2-level cervical disk herniation with radicular symptoms conservatively treated with chiropractic care including high-velocity, low-amplitude (HVLA) manipulation with complete resolution of her symptoms.

CLINICAL FEATURES: A 40-year-old woman developed right finger paresthesia and neck pain. Results of electrodiagnostics were normal, but clinical examination revealed subtle findings of cervical radiculopathy. A subsequent magnetic resonance imaging revealed a large right posterolateral disk protrusion and spur impinging on the right hemicord with moderate to severe central canal and right neuroforaminal stenosis at C5-6 and C6-7. She was treated with HVLA manipulation to the cervical spine, as well as soft tissue techniques, traction, nonsteroidal anti-inflammatory drugs, and exercise.

INTERVENTION AND OUTCOME: Her clinical findings and symptoms resolved within 90 days of initiating care and did not return in 1 year. There were no untoward effects, including transient ones.

CONCLUSION: This case describes the clinical presentation and course of a patient with multilevel large herniated disks and associated radiculopathy who was treated with HVLA manipulation and other conservative approaches and appeared to have good outcomes.

J Chiropr Med. 2008 Mar;7(1):1-8.

A feasibility study assessing manual therapies to different regions of the spine for patients with subacute or chronic neck pain.
Strunk RG, Hondras MA.

Instructor/Research Clinician, Cleveland Chiropractic College, Kansas City, MO 64131.

Abstract
OBJECTIVE: The purpose of this project was to develop and test protocols for a randomized clinical trial of a combined therapeutic approach (thoracic spine and sacroiliac joint high-velocity, low-amplitude spinal manipulation [HVLA SM] + cervical spine postisometric relaxation) and cervical spine HVLA SM for patients with subacute or chronic neck pain.

METHODS: Patients were recruited in the Quad Cities in Iowa and Illinois. After a baseline assessment visit, eligible patients were randomly assigned to cervical spine HVLA SM or to the combined therapeutic approach for 4 treatment visits over 2 weeks. Outcome assessments included the Neck Disability Index, visual analog scale, and posttreatment response questionnaire. Patient outcomes were not aggregated or compared by treatment group.

RESULTS: It took approximately 8 months of planning, which included the development of forms and protocols, pretesting the forms, and training staff and clinicians in the standardized protocols. Twelve participants were screened, and 6 patients were enrolled and randomly allocated to care over a 6-week period. All patients completed 5 visits. Five of 6 patients had an improvement on the Neck Disability Index. On the visual analog scale, 2 patients improved at 2 weeks, whereas the other 4 got worse. Five patients completed the posttreatment response questionnaire; 2 of the 5 indicated they experienced discomfort or an unpleasant reaction from the study treatments.

CONCLUSIONS: Designing a successful feasibility randomized clinical trial requires considerable planning, development and pretesting of the forms and protocols, and training clinicians and staff for standardized protocols. Patients were willing to be randomized, follow treatment protocols, complete baseline and outcome assessments, and return 83% of the follow-up questionnaires.

Chiropr Osteopat. 2007 Jul 19;15:10.

A case report of a patient with upper extremity symptoms: differentiating radicular and referred pain.
Daub CW.

[email protected]

Abstract
BACKGROUND: Similar upper extremity symptoms can present with varied physiologic etiologies. However, due to the multifaceted nature of musculoskeletal conditions, a definitive diagnosis using physical examination and advanced testing is not always possible. This report discusses the diagnosis and case management of a patient with two episodes of similar upper extremity symptoms of different etiologies.

CASE PRESENTATION: On two separate occasions a forty-four year old female patient presented to a chiropractic office with a chief complaint of insidious right-sided upper extremity symptoms. During each episode she reported similar pain and parasthesias from her neck and shoulder to her lateral forearm and hand. During the first episode the patient was diagnosed with a cervical radiculopathy. Conservative treatment, including manual cervical traction, spinal manipulation and neuromobilization, was initiated and resolved the symptoms. Approximately eighteen months later the patient again experienced a severe acute flare-up of the upper extremity symptoms. Although the subjective complaint was similar, it was determined that the pain generator of this episode was an active trigger point of the infraspinatus muscle. A diagnosis of myofascial referred pain was made and a protocol of manual trigger point therapy and functional postural rehabilitative exercises improved the condition.

CONCLUSION: In this case a thorough physical evaluation was able to differentiate between radicular and referred pain. By accurately identifying the pain generating structures, the appropriate rehabilitative protocol was prescribed and led to a successful outcome for each condition. Conservative manual therapy and rehabilitative exercises may be an effective treatment for certain cases of cervical radiculopathy and myofascial referred pain.

J Healthc Qual. 2006 Nov-Dec;28(6):32-9.

Assessment of chiropractic outcomes for low back pain and neck pain: a health plan quality incentive model.
Woodburn J, Branson R, Pavoloni G, Lin CC, Fritts M, Goertz C.

MinuteClinic, Inc., Minnepolis, MH, USA. [email protected]

Abstract
Blue Cross and Blue Shield of Minnesota conducted a quality improvement project to quantify and improve the clinical and functional outcomes of low back pain and neck pain patients in a chiropractic network. Improved outcomes were encouraged through a financial incentive for implementation of standard clinical outcome measurement tools, quarterly feedback to individual practices, and a face-to-face meeting to share best practices. Although a large database on baseline neck pain and low back pain and functional disability was generated, and clinically and statistically significant improvements in outcomes were documented, progressive improvement in outcomes over the 4-year project period was not found.

J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):215-27.

Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials.
Vernon H, Humphreys K, Hagino C.

Canadian Memorial Chiropractic College, Toronto, ON, Canada. [email protected]

Erratum in:

J Manipulative Physiol Ther. 2007 Jul;30(6):473-8.

Abstract
OBJECTIVE: This study provides a systematic analysis of group change scores in randomized clinical trials of chronic neck pain not due to whiplash and not including headache or arm pain treated with manual therapy.

METHODS: A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2005. Only clinical trials scoring above 11.5 (Amsterdam-Maastricht Scale) were included in the analysis.

RESULTS: From 1980 citations, 19 publications were selected. Of the 16 trials analyzed (3 were rejected for poor quality), 9 involved spinal manipulation (12 groups), 5 trials (5 groups) were for spinal mobilization or nonmanipulative manual therapy (1 trial overlapped), and 2 trials (2 groups) involved massage therapy. No trials included trigger point therapy or manual traction of the neck. For manipulation studies, the mean effect size (ES) at 6 weeks for 7 trials (10 groups) was 1.63 (95% confidence interval [CI], 1.13-2.13); 1.56 (95% CI, 0.73-2.39) at 12 weeks for 4 trials (5 groups); 1.22 (95% CI, 0.38-2.06) from 52 to 104 weeks for 2 trials (2 groups). For mobilization studies, 1 trial reported an ES of 2.5 at 6 weeks, 2 trials reported full recovery in 63.8% to 71.7% of subjects at 7 to 52 weeks, and 1 trial reported greater than 2/10 point pain score reduction in 78.3% of subjects at 4 weeks. For massage studies, 1 reported an ES of 0.03 at 6 weeks, whereas the other reported mean change scores of 7.89/100 and 14.4/100 at 1 and 12 weeks of, respectively.

CONCLUSIONS: There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment. The current evidence does not support a similar level of benefit from massage.

J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):165-70.

Chiropractic care of musculoskeletal disorders in a unique population within Canadian community health centers.
Garner MJ, Aker P, Balon J, Birmingham M, Moher D, Keenan D, Manga P.

Carlington Community and Health Services, Ottawa, Ontario, Canada. [email protected]

Abstract
OBJECTIVE: This study was part of a larger demonstration project integrating chiropractic care into publicly funded Canadian community health centers. This pre/post study investigated the effectiveness of chiropractic care in reducing pain and disability as well as improving general health status in a unique population of urban, low-income, and multiethnic patients with musculoskeletal (MSK) complaints.

METHODS: All patients who presented to one of two community health center-based chiropractic clinics with MSK complaints between August 2004 and December 2005 were recruited to participate in this study. Outcomes were assessed by a general health measure (Short Form-12), a pain scale (VAS), and site-specific disability indexes (Roland-Morris Questionnaire and Neck Disability Index), which were administered before and after a 12-week treatment period.

RESULTS: Three hundred twenty-four patients with MSK conditions were recruited into the study, and 259 (80.0%) of them were followed to the study's conclusion. Clinically important and statistically significant positive changes were observed for all outcomes (Short Form-12: physical composite score mean change = 4.9, 95% confidence interval [CI] = 3.8-6.0; VAS: current pain mean change = 2.3, 95% CI = 1.9-2.6; Neck Disability Index: mean change = 6.8, 95% CI = 5.4-8.1; Roland-Morris Questionnaire: mean change = 4.3, 95% CI = 3.6-5.1). No adverse events were reported.

CONCLUSIONS: Patients of low socioeconomic status face barriers to accessing chiropractic services. This study suggests that chiropractic care reduces pain and disability as well as improves general health status in patients with MSK conditions. Further studies using a more robust methodology are needed to investigate the efficacy and cost-effectiveness of introducing chiropractic care into publicly funded health care facilities.

J Am Geriatr Soc. 2000 May;48(5):534-45.

Chiropractic care for patients aged 55 years and older: report from a practice-based research program.
Hawk C, Long CR, Boulanger KT, Morschhauser E, Fuhr AW.

Palmer Center for Chiropractic Research, Davenport, Iowa 52803, USA.

Abstract
OBJECTIVE: To characterize patients aged 55 years and older and features of chiropractic care provided to them.

DESIGN: Observational, practice-based research study.

SETTING: Chiropractic offices in the United States and Canada, 1997-1998.

PARTICIPANTS: Chiropractors in 96 practices in 32 states and two Canadian provinces collected data on 805 eligible patients aged 55 years and older during a 12-week study period.

MEASUREMENTS: In addition to questionnaires on practice characteristics, patient demographics, chief complaints, and health habits, two standardized instruments were administered: for general health status, the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12); and for disability related to chronic pain, the Pain Disability Index (PDI).

RESULTS: Of 805 study patients, 60.1% were women and' 94.7% were white. Overweight patients comprised 38.6% and obese 20.6% (n = 656) of the total; 9.7% of patients were hypertensive (n = 590). Smoking was reported by 12.7% and 50.2% reported regular exercise. The Physical Component Summary scores of the SF-12 seemed somewhat lower than population norms, whereas the Mental Component Summary scores differed very little from norms. Chief complaints were predominantly pain-related (72.3%), most commonly back pain (32.9%). The PDI mean baseline score for chronic patients was 16.3 (scale, 0-70), and 40.6% of study patients reported using at least one pain medication (prescription or nonprescription) more than three times per week. More than half of complaints (54.9%) had onsets more than 6 weeks before the baseline visit. For 66.6% of subjects, a chiropractor was the only provider for their current complaint. In addition to manipulation, most common features of care were recommendations on exercise (41.0%), heat or cold applications (40.8%), and food supplements (24.5%). At 4 weeks, 19.6% were discharged, 58.8% continued treatment, and 20.1% had discontinued care (self-discharged). For these three groups, those with higher PDI mean baseline scores showed more change at 4 weeks. For patients who were discharged by the doctor, the proportion of reported pain medication use decreased 7.3% from baseline to 4 weeks, increased for patients who discontinued care, and remained about the same for those continuing care.

CONCLUSIONS: Further investigation of the PDI and a decrease in pain medication use as outcome measures seems warranted. The descriptive information in this study may assist providers of care to older adults to better understand their patients' use of chiropractic care.

J Manipulative Physiol Ther. 1994 Feb;17(2):119-23.

Chiropractic treatment of cervical radiculopathy caused by a herniated cervical disc.
Brouillette DL, Gurske DT.

Abstract
OBJECTIVE: To present a case of cervical radiculopathy, caused by an MRI documented herniated cervical disc, which was treated with conservative care including chiropractic manipulative therapy.

CLINICAL FEATURES: A 60-yr-old woman was treated by a chiropractor for symptoms including a deep, constant, burning ache in the left arm, and severe neck and left shoulder pain. A diagnosis of acute herniated cervical disc was made based on the findings of physical examination and an MRI study of the patient's cervical spine. Important orthopedic findings included exacerbation of the radicular symptomatology with the performance of Valsalva's and cervical compression tests. Neurologic findings included absent biceps and hyporeflexive triceps reflexes on the left, as well as C6 sensory deficit and C7 and C8 sensory hypesthesia. The primary finding on the MRI scan was posterior and lateral herniation on the C6-7 disc.

INTERVENTION AND OUTCOME: Treatment included chiropractic manipulative therapy, longitudinal cervical traction and interferential therapy. The patient began a regular schedule of treatments, which started on a daily basis but were gradually reduced as the patient progressed. By the third week of treatment, neck and shoulder pain was completely resolved. Subjective evaluation indicated the radicular pain to be improved by 60% within 6 wk. The patient's pain, numbness and grip strength returned to normal within 5 months.

CONCLUSION: Conservative treatment including chiropractic manipulative therapy seems to be a reasonable alternative to surgery, for cervical radiculopathy caused by a herniated cervical disc. Clinical trials should be performed to evaluate long term success rate, risk of permanent disability, rate of recovery and cost effectiveness of this and other forms of treatment for cervical radiculopathy caused by herniated nucleus pulposus.

 
關於脊醫治療及腰背痛的醫學研究
J Manipulative Physiol Ther. 2000 Jun;23(5):307-11.

Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis.
McMorland G, Suter E.

Hillhurst Chiropractic Office, Calgary, Canada.

Abstract
BACKGROUND: Evidence suggests that spinal manipulation is an effective treatment for mechanical neck and low-back pain (LBP). Treatment efficacy is important to establish for these symptoms because combined they account for a considerable amount of disability and substantial associated direct and indirect costs to society.

OBJECTIVE: The purpose of this study was to examine the outcome of patients undergoing chiropractic treatment for mechanical neck or LBP. Design and Setting: A retrospective, outcome-based analysis was done for patients seeking care at a private chiropractic practice over a 1-year period. A total of 512 files were reviewed, with 119 patients selected for inclusion. Patients were included if their chief symptom was uncomplicated mechanical neck or LBP. Diagnoses included cervical, lumbar, or sacroiliac joint sprain/strain (International Code of Diagnostics version 9 [ICD-9] code: 847.1, 847.3, 846.1, respectively), discogenic LBP (ICD-9: 722.1), and headaches (ICD-9: 784.0) because many patients with neck pain presented with concomitant headaches. Disability and pain were measured with the modified Oswestry scale (for the patients with LBP), Neck Disability Index, and an 11-box visual analogue pain scale before and after treatment. Treatment consisted of spinal manipulation, various soft-tissue techniques, home-care instructions, and ergonomic and return-to-activity advice, including rehabilitative exercises. Patients received an average of 12 treatments over a 4-week period. Statistical analysis was performed on pretreatment and posttreatment values for both disability and pain. Stratification was based on duration (acute/subacute, chronic, acute exacerbation of a chronic condition) and severity (mild, moderate, or severe) of symptoms.

RESULTS: Statistically significant reductions in disability and pain scores were achieved in all groups. An average 52.5% and 52.9% reduction in pain and disability, respectively, was achieved in the low-back group. The chronic LBP group realized a less statistically significant reduction of pain and disability (19.7% and 19.8%, respectively) than the acute/subacute (66.8% and 62.5%) or the chronic/recurrent group (56. 5% and 63.4%). The differences were statistically significant. Patients with neck pain had an average 53.8% and 48.4% reduction in their pain and disability, respectively. Patients with concomitant neck pain and headaches had statistically significant higher pretreatment and posttreatment disability and pain scores than those with only neck pain. There was no statistically significant difference in outcomes between groups stratified according to pain intensity.

CONCLUSIONS: Patients attending a private chiropractic clinic for treatment of mechanical neck pain or LBP had statistically significant reductions in their pain-related disability after treatment. These results indicate that chiropractic manipulation is beneficial for the treatment of mechanical neck pain and LBP. However, care must be taken when drawing conclusions from these outcomes. The study design does not account for the natural history of low back- or neck pain-related disability and therefore does not allow for claims of treatment efficacy. In addition, it has been suggested that patients presenting to medical doctors with these symptoms have significant overlying comorbidity when compared with patients presenting to a chiropractor.

BMC Musculoskelet Disord. 2010 Oct 19;11:241.

Low back pain in junior Australian Rules football: a cross-sectional survey of elite juniors, non-elite juniors and non-football playing controls.
Hoskins W, Pollard H, Daff C, Odell A, Garbutt P, McHardy A, Hardy K, Dragasevic G.

Department of Chiropractic, Macquarie University, Sydney, NSW 2109, Australia. [email protected]

Abstract
BACKGROUND: Low back pain in junior Australian Rules footballers has not been investigated despite findings that back pain is more prevalent, severe and frequent in senior footballers than non-athletic controls and findings that adolescent back pain is a strong predictor for adult back pain. The aim of this study was to determine the prevalence, intensity, quality and frequency of low back pain in junior Australian Rules footballers and a control group and to compare this data between groups.

METHODS: A cross-sectional survey of male non-elite junior (n = 60) and elite junior players (n = 102) was conducted along with a convenience sample of non-footballers (school children) (n = 100). Subjects completed a self-reported questionnaire on low back pain incorporating the Quadruple Visual Analogue Scale and McGill Pain Questionnaire (short form), along with additional questions adapted from an Australian epidemiological study. Linear Mixed Model (Residual Maximum Likelihood) methods were used to compare differences between groups. Log-linear models were used in the analysis of contingency tables.

RESULTS: For current, average and best low back pain levels, elite junior players had higher pain levels (p < 0.001), with no difference noted between non-elite juniors and controls for average and best low back pain. For low back pain at worst, there were significant differences in the mean pain scores. The difference between elite juniors and non-elite juniors (p = 0.040) and between elite juniors and controls (p < 0.001) was significant, but not between non-elite juniors and controls. The chance of suffering low back pain increases from 45% for controls, through 55% for non-elite juniors to 66.7% for elite juniors. The chance that a pain sufferer experiences chronic pain is 16% for controls and 41% for non-elite junior and elite junior players. Elite junior players experienced low back pain more frequently (p = 0.002), with no difference in frequency noted between non-elite juniors and controls. Over 25% of elite junior and non-elite junior players reported that back pain impacted their performance some of the time or greater.

CONCLUSIONS: This study demonstrated that when compared with non-elite junior players and non-footballers of a similar age, elite junior players experience back pain more severely and frequently and have higher prevalence and chronicity rates.

Spine J. 2010 Dec;10(12):1055-64.

The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.
Bishop PB, Quon JA, Fisher CG, Dvorak MF.

International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada. [email protected]

Abstract
BACKGROUND CONTEXT: Evidence-based clinical practice guidelines (CPGs) for the management of patients with acute mechanical low back pain (AM-LBP) have been defined on an international scale. Multicenter clinical trials have demonstrated that most AM-LBP patients do not receive CPG-based treatments. To date, the value of implementing full and exclusively CPG-based treatment remains unclear.

PURPOSE: To determine if full CPGs-based study care (SC) results in greater improvement in functional outcomes than family physician-directed usual care (UC) in the treatment of AM-LBP.

STUDY DESIGN/SETTING: A two-arm, parallel design, prospective, randomized controlled clinical trial using blinded outcome assessment. Treatment was administered in a hospital-based spine program outpatient clinic.

PATIENT SAMPLE: Inclusion criteria included patients aged 19 to 59 years with Quebec Task Force Categories 1 and 2 AM-LBP of 2 to 4 weeks' duration. Exclusion criteria included "red flag" conditions and comorbidities contraindicating chiropractic spinal manipulative therapy (CSMT).

OUTCOME MEASURES: Primary outcome: improvement from baseline in Roland-Morris Disability Questionnaire (RDQ) scores at 16 weeks. Secondary outcomes: improvements in RDQ scores at 8 and 24 weeks; and in Short Form-36 (SF-36) bodily pain (BP) and physical functioning (PF) scale scores at 8, 16, and 24 weeks.

METHODS: Patients were assessed by a spine physician, then randomized to SC (reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar CSMT, and return to work within 8 weeks), or family physician-directed UC, the components of which were recorded.

RESULTS: Ninety-two patients were recruited, with 36 SC and 35 UC patients completing all follow-up visits. Baseline prognostic variables were evenly distributed between groups. The primary outcome, the unadjusted mean improvement in RDQ scores, was significantly greater in the SC group than in the UC group (p=.003). Regarding unadjusted mean changes in secondary outcomes, improvements in RDQ scores were also greater in the SC group at other time points, particularly at 24 weeks (p=.004). Similarly, improvements in SF-36 PF scores favored the SC group at all time points; however, these differences were not statistically significant. Improvements in SF-36 BP scores were similar between groups. In repeated-measures analyses, global adjusted mean improvement was significantly greater in the SC group in terms of RDQ (p=.0002), nearly significantly greater in terms of SF-36 PF (p=.08), but similar between groups in terms of SF-36 BP (p=.27).

CONCLUSIONS: This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.

Chiropr Osteopat. 2010 Jul 30;18:21.

Preliminary study into the components of the fear-avoidance model of LBP: change after an initial chiropractic visit and influence on outcome.
Field JR, Newell D, McCarthy PW.

Private practice, Back2Health, 2 Charles Street, Petersfield, Hants, GU32 3EH, UK. [email protected]

Abstract
BACKGROUND: In the last decade the sub grouping of low back pain (LBP) patients according to their likely response to treatment has been identified as a research priority. As with other patient groups, researchers have found few if any factors from the case history or physical examination that are helpful in predicting the outcome of chiropractic care. However, in the wider LBP population psychosocial factors have been identified that are significantly prognostic. This study investigated changes in the components of the LBP fear-avoidance beliefs model in patients pre- and post- their initial visit with a chiropractor to determine if there was a relationship with outcomes at 1 month.

METHODS: Seventy one new patients with lower back pain as their primary complaint presenting for chiropractic care to one of five clinics (nine chiropractors) completed questionnaires before their initial visit (pre-visit) and again just before their second appointment (post-visit). One month after the initial consultation, patient global impression of change (PGIC) scores were collected. Pre visit and post visit psychological domain scores were analysed for any association with outcomes at 1 month.

RESULTS: Group mean scores for Fear Avoidance Beliefs (FAB), catastrophisation and self-efficacy were all improved significantly within a few days of a patient's initial chiropractic consultation. Pre-visit catastrophisation as well as post-visit scores for catastrophisation, back beliefs (inevitability) and self-efficacy were weakly correlated with patient's global impression of change (PGIC) at 1 month. However when the four assessed psychological variables were dichotomised about pre-visit group medians those individuals with 2 or more high variables post-visit had a substantially increased risk (OR 36.4 (95% CI 6.2-213.0) of poor recovery at 1 month. Seven percent of patients with 1 or fewer adverse psychological variables described poor benefit compared to 73% of those with 2 or more.

CONCLUSIONS: The results presented suggest that catastrophisation, FAB and low self-efficacy could be potential barriers to early improvement during chiropractic care. In most patients presenting with higher psychological scores these were reduced within a few days of an initial chiropractic visit. Those patients who exhibited higher adverse psychology post-initial visit appear to have an increased risk of poor outcome at 1 month.

J Can Chiropr Assoc. 2010 Jun;54(2):118-31.

Outcome measures and their everyday use in chiropractic practice.
Hinton PM, McLeod R, Broker B, Maclellan CE.

Private practice, Prince Albert, SK. Tel: 306 922-7028 begin_of_the_skype_highlighting 306 922-7028 end_of_the_skype_highlighting. Email: [email protected]

Abstract
OBJECTIVES: To describe the extent to which chiropractors utilize standardized outcome and various clinical measures to systematically document patients' baseline health status and responses to treatment, with particular consideration being given towards quantifiable outcome instruments.

STUDY DESIGN: Cross-sectional mailed survey.

PARTICIPANTS: Registered chiropractors in the province of Saskatchewan.

METHODS: A survey was mailed to all registrants of the Chiropractors' Association of Saskatchewan. Respondents graded their frequency of using various standardized pencil-and-paper instruments and functional chiropractic, orthopaedic and neurological tests in the contexts of both the initial intake assessment ('always,' 'commonly,' 'occasionally,' or 'never') and the course of subsequent treatment (after 'each visit,' after '9-12 visits,' 'annually,' when patient 'not responding,' on 'dismissal/discharge,' 'never' or for some 'other' reason). Data were tabulated for all item and response category combinations as frequencies and percentages using the total sample size as the denominator.

RESULTS: Of 164 registered chiropractors, 62 (38%) returned a completed questionnaire. A pain diagram was the most commonly used subjective outcome measure and was administered routinely (either "always" or "commonly") by 75% of respondents, at either the initial consultation or during a subsequent visit. Numerical rating and visual analogue scales were less popular (routinely used by 59% and 42% respectively). The majority of respondents (80%) seldom ("occasionally" or "never") used spine pain-specific disability indices such as the Low Back Revised Oswestry, Neck Disability Index or the Roland-Morris Questionnaire. As well, they did not use standardized psychosocial instruments such as the Beck Depression Index, or general health assessment measures such as the SF-36 or SF-12 questionnaire. Neurological testing was the most commonly used objective outcome measure. Most respondents (84% to 95%) indicated that they continually monitored neurological status through dermatomal, manual muscle strength and deep tendon reflex testing. Ranges of motion were routinely measured by 95% of respondents, usually visually (96%) rather than goniometrically or by some other specialized device (7%).

CONCLUSIONS: Our findings suggest that the majority of chiropractors do not use psychosocial questionnaires or condition-specific disability indices to document baseline or subsequent changes in health status. Chiropractors are more likely to rely on medical history taking and pain drawings during an initial intake assessment, as well as neurological and visually estimated range of motion testing during both initial intake and subsequent treatment visits.

Chiropr Osteopat. 2010 Apr 29;18:8.

The Nordic back pain subpopulation program: can low back pain patterns be predicted from the first consultation with a chiropractor? A longitudinal pilot study.
Kongsted A, Leboeuf-Yde C.

The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M, Denmark. [email protected]

Abstract
BACKGROUND: It is widely believed that non-specific low back pain (LBP) consists of a number of subgroups which should be identified in order to improve treatment effects. In order to identify subgroups, patient characteristics that relate to different outcomes are searched for. However, LBP is often fluctuating or recurring rather than clearly limited in time. Therefore it would be relevant to consider outcome after completed treatment from a longitudinal perspective (describing "course patterns") instead of defining it from an arbitrarily selected end-point.

AIMS: The objectives of this pilot study were to investigate the interobserver reliability of a diagnostic classification system and to evaluate whether diagnostic classes or other baseline characteristics are associated with the LBP course pattern over a period of 18 weeks.

METHODS: Patients visiting one of 7 chiropractors because of LBP were classified according to a diagnostic classification system, which includes end-range loading, SI-joint pain provocation tests, neurological examination and tests for muscle tenderness and abnormal nerve tension. In addition, age, gender, duration of pain and presence of leg pain were registered in the patient's file. By weekly SMS-messages on their mobile phones, patients were asked how many days they had LBP the preceding week, and these answers were transformed into pain course patterns and the total number of LBP days.

RESULTS: A total of 110 patients were included and 76 (69%) completed follow-up. Thirty-five patients were examined by two chiropractors. The agreement regarding diagnostic classes was 83% (95% CI: 70 - 96). The diagnostic classes were associated with the pain course patterns and number of LBP days. Patients with disc pain had the highest number of LBP days and patients with muscular pain reported the fewest (35 vs. 12 days, p < 0.01). Men had better outcome than women (17 vs. 29 days, p < 0.01) and patients without leg pain tended to have fewer LBP days than those with leg pain (21 vs.31 days, p = 0.06). Duration of LBP at the first visit was not associated with outcome.

CONCLUSIONS: The study indicated that there is a clinically meaningful relationship between diagnostic classes and the course of LBP. This should be evaluated in more depth.

Cochrane Database Syst Rev. 2010 Apr 14;(4):CD005427.

Combined chiropractic interventions for low-back pain.
Walker BF, French SD, Grant W, Green S.

School of Chiropractic and Sports Science, Murdoch University, Faculty of Health Sciences, Murdoch, Australia, 6150.

Abstract
BACKGROUND: Chiropractors commonly use a combination of interventions to treat people with low-back pain (LBP).

OBJECTIVES: To determine the effects of combined chiropractic interventions (that is, a combination of therapies, other than spinal manipulation alone) on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with LBP, aged 18 and older.

SEARCH STRATEGY: We searched: The Cochrane Back Review Group Trials Register (May 2009), CENTRAL (The Cochrane Library 2009, Issue 2), and MEDLINE (from January 1966), EMBASE (from January 1980), CINAHL (from January 1982), MANTIS (from Inception) and the Index to Chiropractic Literature (from Inception) to May 2009. We also screened references of identified articles and contacted chiropractic researchers.

SELECTION CRITERIA: All randomised trials comparing the use of combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies.

DATA COLLECTION AND ANALYSIS: At least two review authors selected studies, assessed the risk of bias, and extracted the data using standardised forms. Both descriptive synthesis and meta-analyses were performed.

MAIN RESULTS: We included 12 studies involving 2887 participants with LBP. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of sub-populations of people with LBP.No trials were located of combined chiropractic interventions compared to no treatment. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (SMD -0.25 (95% CI -0.46 to -0.04) and MD -0.89 (95%CI -1.60 to -0.18)) compared to other treatments, but there was no significant difference in long-term pain (MD -0.46 (95% CI -1.18 to 0.26)). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 (95% CI -0.70 to -0.02)). However, the effect was small and all studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and for studies that had a mixed population of LBP.

AUTHORS' CONCLUSIONS: Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.

Trials. 2010 Mar 8;11:24.

Individualized chiropractic and integrative care for low back pain: the design of a randomized clinical trial using a mixed-methods approach.
Westrom KK, Maiers MJ, Evans RL, Bronfort G.

Northwestern Health Sciences University, Wolfe-Harris Center for Clinical Studies, Bloomington, MN 55431, USA. [email protected]

Abstract
BACKGROUND: Low back pain (LBP) is a prevalent and costly condition in the United States. Evidence suggests there is no one treatment which is best for all patients, but instead several viable treatment options. Additionally, multidisciplinary management of LBP may be more effective than monodisciplinary care. An integrative model that includes both complementary and alternative medicine (CAM) and conventional therapies, while also incorporating patient choice, has yet to be tested for chronic LBP.The primary aim of this study is to determine the relative clinical effectiveness of 1) monodisciplinary chiropractic care and 2) multidisciplinary integrative care in 200 adults with non-acute LBP, in both the short-term (after 12 weeks) and long-term (after 52 weeks). The primary outcome measure is patient-rated back pain. Secondary aims compare the treatment approaches in terms of frequency of symptoms, low back disability, fear avoidance, self-efficacy, general health status, improvement, satisfaction, work loss, medication use, lumbar dynamic motion, and torso muscle endurance. Patients' and providers' perceptions of treatment will be described using qualitative methods, and cost-effectiveness and cost utility will be assessed.

METHODS AND DESIGN: This paper describes the design of a randomized clinical trial (RCT), with cost-effectiveness and qualitative studies conducted alongside the RCT. Two hundred participants ages 18 and older are being recruited and randomized to one of two 12-week treatment interventions. Patient-rated outcome measures are collected via self-report questionnaires at baseline, and at 4, 12, 26, and 52 weeks post-randomization. Objective outcome measures are assessed at baseline and 12 weeks by examiners blinded to treatment assignment. Health care cost data is collected by self-report questionnaires and treatment records during the intervention phase and by monthly phone interviews thereafter. Qualitative interviews, using a semi-structured format, are conducted with patients at the end of the 12-week treatment period and also with providers at the end of the trial.

DISCUSSION: This mixed-methods randomized clinical trial assesses clinical effectiveness, cost-effectiveness, and patients' and providers' perceptions of care, in treating non-acute LBP through evidence-based individualized care delivered by monodisciplinary or multidisciplinary care teams

BMC Musculoskelet Disord. 2007 Sep 18;8:94.

Chiropractic and exercise for seniors with low back pain or neck pain: the design of two randomized clinical trials.
Maiers MJ, Hartvigsen J, Schulz C, Schulz K, Evans RL, Bronfort G.

Northwestern Health Sciences University, Wolfe-Harris Center for Clinical Studies, 2501 West 84th Street, Bloomington, MN 55431, USA. [email protected]

Abstract
BACKGROUND: Low back pain (LBP) and neck pain (NP) are common conditions in old age, leading to impaired functional ability and decreased independence. Manual and exercise therapies are common and effective therapies for the general LBP and NP populations. However, these treatments have not been adequately researched in older LBP and NP sufferers. The primary aim of these studies is to assess the relative clinical effectiveness of 1) manual treatment plus home exercise, 2) supervised rehabilitative exercise plus home exercise, and 3) home exercise alone, in terms of patient-rated pain, for senior LBP and NP patients. Secondary aims are to compare the three treatment approaches in regards to patient-rated disability, general health status, satisfaction, improvement and medication use, as well as objective outcomes of spinal motion, trunk strength and endurance, and functional ability. Cost-effectiveness and cost-utility will also be assessed. Finally, using qualitative methods, older LBP and NP patient's perceptions of treatment will be explored and described.

METHODS/DESIGN: This paper describes the design of two multi-methods clinical studies focusing on elderly patients with non-acute LBP and NP. Each study includes a randomized clinical trial (RCT), a cost-effectiveness study alongside the RCT, and a qualitative study. Four hundred and eighty participants (240 per study), ages 65 and older, will be recruited and randomized to one of three, 12-week treatment programs. Patient-rated outcome measures are collected via self-report questionnaires at baseline and at 4, 12, 26, and 52 weeks post-randomization. Objective outcomes are assessed by examiners masked to treatment assignment at baseline and 12 weeks. Health care cost data is collected through standardized clinician forms, monthly phone interviews, and self-report questionnaires throughout the study. Qualitative interviews using a semi-structured format are conducted at the end of the 12 week treatment period.

DISCUSSION: To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers
BMC Public Health. 2007 Sep 20;7:254.

Multidisciplinary outpatient care program for patients with chronic low back pain: design of a randomized controlled trial and cost-effectiveness study [ISRCTN28478651].
Lambeek LC, Anema JR, van Royen BJ, Buijs PC, Wuisman PI, van Tulder MW, van Mechelen W.

Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands. [email protected]

Abstract
BACKGROUND: Chronic low back pain (LBP) is a major public and occupational health problem, which is associated with very high costs. Although medical costs for chronic LBP are high, most costs are related to productivity losses due to sick leave. In general, the prognosis for return to work (RTW) is good but a minority of patients will be absent long-term from work. Research shows that work related problems are associated with an increase in seeking medical care and sick leave. Usual medical care of patients is however, not specifically aimed at RTW. The objective is to present the design of a randomized controlled trial, i.e. the BRIDGE-study, evaluating the effectiveness in improving RTW and cost-effectiveness of a multidisciplinary outpatient care program situated in both primary and outpatient care setting compared with usual clinical medical care for patients with chronic LBP.

METHODS/DESIGN: The design is a randomized controlled trial with an economic evaluation alongside. The study population consists of patients with chronic LBP who are completely or partially sick listed and visit an outpatient clinic of one of the participating hospitals in Amsterdam (the Netherlands). Two interventions will be compared. 1. a multidisciplinary outpatient care program consisting of a workplace intervention based on participatory ergonomics, and a graded activity program using cognitive behavioural principles. 2. usual care provided by the medical specialist, the occupational physician, the patient's general practitioner and allied health professionals. The primary outcome measure is sick leave duration until full RTW. Sick leave duration is measured monthly by self-report during one year. Data on sick leave during one-year follow-up are also requested form the employers. Secondary outcome measures are pain intensity, functional status, pain coping, patient satisfaction and quality of life. Outcome measures are assessed before randomization and 3, 6, and 12 months later. All statistical analysis will be performed according to the intension-to-treat principle.

DISCUSSION: Usual care of primary and outpatient health services isn't directly aimed at RTW, therefore it is desirable to look for care which is aimed at RTW. Research shows that several occupational interventions in primary care are aimed at RTW. They have shown a significant reduction of sick leave for employee with LBP. If a comparable reduction of sick leave duration of patients with chronic LBP of who attend an outpatient clinic can be achieved, such reductions will be obviously substantial for the Netherlands and will have a considerable impact.

BMC Musculoskelet Disord. 2006 Feb 23;7:16.

A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study.
Murphy DR, Hurwitz EL, Gregory AA, Clary R.

Rhode Island Spine Center, Pawtucket, RI 02860, USA. [email protected]

Abstract
BACKGROUND: While it is widely held that non-surgical management should be the first line of approach in patients with lumbar spinal stenosis (LSS), little is known about the efficacy of non-surgical treatments for this condition. Data are needed to determine the most efficacious and safe non-surgical treatment options for patients with LSS. The purpose of this paper is to describe the clinical outcomes of a novel approach to patients with LSS that focuses on distraction manipulation (DM) and neural mobilization (NM).

METHODS: This is a prospective consecutive case series with long term follow up (FU) of fifty-seven consecutive patients who were diagnosed with LSS. Two were excluded because of absence of baseline data or failure to remain in treatment to FU. Disability was measured using the Roland Morris Disability Questionnaire (RM) and pain intensity was measured using the Three Level Numerical Rating Scale (NRS). Patients were also asked to rate their perceived percentage improvement.

RESULTS: The mean patient-rated percentage improvement from baseline to the end to treatment was 65.1%. The mean improvement in disability from baseline to the end of treatment was 5.1 points. This was considered to be clinically meaningful. Clinically meaningful improvement in disability from baseline to the end of treatment was seen in 66.7% of patients. The mean improvement in "on average" pain intensity was 1.6 points. This did not reach the threshold for clinical meaningfulness. The mean improvement in "at worst" pain was 3.1 points. This was considered to be clinically meaningful. The mean duration of FU was 16.5 months. The mean patient-rated percentage improvement from baseline to long term FU was 75.6%. The mean improvement in disability was 5.2 points. This was considered to be clinically meaningful. Clinically meaningful improvement in disability was seen in 73.2% of patients. The mean improvement in "on average" pain intensity from baseline to long term FU was 3.0 points. This was considered to be clinically meaningful. The mean improvement in "at worst" pain was 4.2 points. This was considered to be clinically meaningful. Only two patients went on to require surgery. No major complications to treatment were noted.

CONCLUSION: A treatment approach focusing on DM and NM may be useful in bringing about clinically meaningful improvement in disability in patients with LSS.

J Manipulative Physiol Ther. 2009 Jun;32(5):330-43.

A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain.
Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC.

Palmer Center for Chiropractic Research, Davenport, Iowa 52803, USA. [email protected]

Comment in:

J Manipulative Physiol Ther. 2009 Sep;32(7):601.

Abstract
OBJECTIVE: Chiropractic care is used by many older patients for low back pain (LBP), but there are no published results of randomized trials examining spinal manipulation (SM) for older adults. The purpose of this study was to compare the effects of 2 biomechanically distinct forms of SM and minimal conservative medical care (MCMC) for participants at least 55 years old with subacute or chronic nonradicular LBP.

METHODS: Randomized controlled trial. The primary outcome variable was low back-related disability assessed with the 24-item Roland Morris Disability questionnaire at 3, 6, 12, and 24 weeks. Participants were randomly allocated to 6 weeks of care including 12 visits of either high-velocity, low-amplitude (HVLA)-SM, low-velocity, variable-amplitude (LVVA)-SM, or 3 visits of MCMC.

RESULTS: Two hundred forty participants (105 women and 135 men) ages 63.1 +/- 6.7 years without significant comorbidities. Adjusted mean Roland Morris Disability change scores (95% confidence intervals) from baseline to the end of active care were 2.9 (2.2, 3.6) and 2.7 (2.0, 3.3) in the LVVA-SM and HVLA-SM groups, respectively, and 1.6 (0.5, 2.8) in the MCMC group. There were no significant differences between LVVA-SM and HVLA-SM at any of the end points. The LVVA-SM group had significant improvements in mean functional status ranging from 1.3 to 2.2 points over the MCMC group. There were no serious adverse events associated with any of the interventions.

CONCLUSIONS: Biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients and both SM procedures were associated with small yet clinically important changes in functional status by the end of treatment for this relatively healthy older population. Participants who received either form of SM had improvements on average in functional status ranging from 1 to 2.2 over those who received MCMC. From an evidence-based care perspective, patient preference and clinical experience should drive how clinicians and patients make the SM procedure decision for this patient population.

J Manipulative Physiol Ther. 2009 Jul-Aug;32(6):414-22.

Characterization of health status and modifiable risk behavior among United States adults using chiropractic care as compared with general medical care.
Ndetan HT, Bae S, Evans MW Jr, Rupert RL, Singh KP.

Parker College Research Institute, Dallas, Tex 75229, USA. [email protected]

Abstract
OBJECTIVE: The causes of death in the United States have moved from infectious to chronic diseases with modifiable behavioral risk factors. Simultaneously, there has been a paradigm shift in health care provisions with increased emphases on prevention and health promotion. Use of professional complementary and alternative medicine, such as chiropractic care, has increased. The purpose of this study was to characterize typical conditions, modifiable risk behaviors, and perceived changes in overall general health of patients seeing chiropractors as compared with general medical doctors in the United States.

METHODS: Secondary analyses of the National Health Interview Survey 2005 adult sample (n = 31,248) were performed. Multiple logistic regression models were applied to assess associations of health conditions/risk behaviors of patients with the doctors (chiropractors vs medical doctors) they saw within the past 12 months.

RESULTS: Respondents who saw/talked to chiropractors were 9.3%. Among these, 21.4% did not see a medical doctor. Comparing chiropractor-only with medical doctor-only patients, we found no significant difference in smoking/alcohol consumption status, but chiropractor-only patients were more likely to be physically active (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8) and less likely to be obese (OR, 0.7; 95% CI, 0.6-0.9). Respondents reporting acute neck (OR, 2.7; 95% CI, 2.2-3.2) and low back pain (OR, 2.4; 95% CI, 2.0-2.8) were more likely to have seen a chiropractor.

CONCLUSIONS: Based on these analyses, Americans seem to be using chiropractic care for acute neck and low back pain more so than for other health conditions. However, there is no marked difference in their overall health promotion habits and changes in overall general health based on health care provider types.

J Chiropr Med. 2009 Sep;8(3):125-30.

Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report.
Dunn AS, Baylis S, Ryan D.

Staff Chiropractor, VA of Western New York, Buffalo, NY 14215; Adjunct Assistant Professor, New York Chiropractic College, Buffalo, NY 14215.

Abstract
OBJECTIVE: This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic.

CLINICAL FEATURES: The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis.

INTERVENTION AND OUTCOME: A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire.

CONCLUSIONS: Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

J Chiropr Med. 2008 Dec;7(4):146-54.

Chiropractic management of a 47-year-old firefighter with lumbar disk extrusion.
Schwab MJ.

Private practice, Schwab Chiropractic Clinic, Eau Claire, WI 54701.

Abstract
OBJECTIVE: This case report describes the effect of exercise-based chiropractic treatment on chronic and intractable low back pain complicated by lumbar disk extrusion.

CLINICAL FEATURES: A 47-year-old male firefighter experienced chronic, unresponsive low back pain. Pre- and posttreatment outcome analysis was performed on numeric (0-10) pain scale, functional rating index, and the low back pain Oswestry data. Secondary outcome assessments included a 1-rep maximum leg press, balancing times, push-ups and sit-ups the patient performed in 60 seconds, and radiographic analysis.

INTERVENTION AND OUTCOME: The patient was treated with Pettibon manipulative and rehabilitative techniques. At 4 weeks, spinal decompression therapy was incorporated. After 12 weeks of treatment, the patient's self-reported numeric pain scale had reduced from 6 to 1. There was also overall improvement in muscular strength, balance times, self-rated functional status, low back Oswestry scores, and lumbar lordosis using pre- and posttreatment radiographic information.

CONCLUSION: Comprehensive, exercise-based chiropractic management may contribute to an improvement of physical fitness and to restoration of function, and may be a protective factor for low back injury. This case suggests promising interventions with otherwise intractable low back pain using a multimodal chiropractic approach that includes isometric strengthening, neuromuscular reeducation, and lumbar spinal decompression therapy.

J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74.

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.
Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C.

Center for Teaching and Learning, Palmer College of Chiropractic, Davenport, Iowa, USA. [email protected]

Abstract
OBJECTIVES: The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP).

METHODS: A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input.

RESULTS: A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies.

CONCLUSIONS: As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):651-8.

Chiropractic management of low back disorders: report from a consensus process.
Globe GA, Morris CE, Whalen WM, Farabaugh RJ, Hawk C; Council on Chiropractic Guidelines and Practice Parameter.

Cleveland Chiropractic College Los Angeles, Los Angeles, CA, USA.

Abstract
OBJECTIVE: Although a number of guidelines addressing manipulation, an important component of chiropractic professional care, exist, none to date have incorporated a broad-based consensus of chiropractic research and clinical experts representing mainstream chiropractic practice into a practical document designed to provide standardized parameters of care. The purpose of this project was to develop such a document.

METHODS: Development of the document began with seed materials, from which seed statements were distilled. These were circulated electronically to the Delphi panel until consensus was reached, which was considered to be present when there was agreement by at least 80% of the panelists.

RESULTS: The panel consisted of 40 clinically experienced doctors of chiropractic, representing 15 chiropractic colleges and 16 states, as well as both the American Chiropractic Association and the International Chiropractic Association. The panel reached 80% consensus of the 27 seed statements after 2 rounds. Specific recommendations regarding treatment frequency and duration, as well as outcome assessment and contraindications for manipulation were agreed upon by the panel.

CONCLUSIONS: A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

J Manipulative Physiol Ther. 2008 Oct;31(8):602-10.

A pilot mixed methods study of patient satisfaction with chiropractic care for back pain.
Rowell RM, Polipnick J.

Palmer College of Chiropractic, Davenport, Iowa 52803, USA. [email protected]

Abstract
OBJECTIVE: Patient satisfaction is important to payers, clinicians, and patients. The concept of satisfaction is multifactorial and measurement is challenging. Our objective was to explore the use of a mixed-methods design to examine patient satisfaction with chiropractic care for low back pain.

METHODS: Patients were treated 3 times per week for 3 weeks. Outcomes were collected at week 3 and week 4. Qualitative interviews were conducted by the treating clinician and a nontreating staff member. Outcome measures were the Roland Morris Back Pain Disability Questionnaire, the visual analog scale for pain, and the Patient Satisfaction Scale. Interviews were recorded and transcribed and analyzed for themes and constructs of satisfaction. We compared qualitative interview data with quantitative outcomes, and qualitative data from 2 different interviewers.

RESULTS: All patients reported high levels of satisfaction. Clinical outcomes were unremarkable with little change noted on visual analog scale and Roland Morris Back Pain Disability Questionnaire scores. We categorized patient comments into the same constructs of satisfaction as those identified for the Patient Satisfaction Scale: Information, Effectiveness, and Caring. An additional construct (Quality of Care) and additional subcategories were identified. Satisfaction with care is not explained by outcome alone. The qualitative data collected from 2 different interviewers had few differences.

CONCLUSION: The results of this study suggest that it is feasible to use a mixed-methods design to examine patient satisfaction. We were able to refine data collection and analysis procedures for the outcome measures and qualitative interview data. We identified limitations and offer recommendations for the next step: the implementation of a larger study.
J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):447-54.

Chiropractic treatment of pregnancy-related low back pain: a systematic review of the evidence.
Stuber KJ, Smith DL.

School of Health and Related Research, The University of Sheffield, Sheffield, UK. [email protected]

Abstract
OBJECTIVE: This study systematically reviewed the published evidence regarding chiropractic care, including spinal manipulation, for pregnancy-related low back pain (LBP).

METHODS: A multimodal search strategy was conducted, including multiple database searches along with reference and journal hand searching. Studies were limited to those published in English and in a peer-reviewed journal or conference proceeding between January 1982 and July 2007. All study designs were considered except single case reports, personal narratives, and qualitative designs. Retrieved articles that met the inclusion criteria were rated for quality by using a validated and reliable checklist.

RESULTS: Six studies met the review's inclusion criteria in the form of 1 quasi-experimental single-group pretest-posttest design, 4 case series, and 1 cross-sectional case series study; their quality scores ranged from 5 to 14 of 27. All of the included studies reported positive results for chiropractic care of LBP during pregnancy. Outcome measure use between the studies was inconsistent as were descriptions of patients, treatments, and treatment schedules.

CONCLUSIONS: Results from the 6 included studies showed that chiropractic care is associated with improved outcomes in pregnancy-related LBP. However, the low-to-moderate quality of evidence of the included studies preclude any definitive statement as to the efficacy of such care because all studies lacked both randomization and control groups. Given the relatively common use of chiropractic care during pregnancy, there is need for higher quality observational studies and controlled trials to determine efficacy.
J Midwifery Womens Health. 2006 Jan-Feb;51(1):e7-10.

Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series.
Lisi AJ.

University of Bridgeport College of Chiropractic. [email protected]

Abstract
Low back pain is a common complaint in pregnancy, with a reported prevalence of 57% to 69% and incidence of 61%. Although such pain can result in significant disability, it has been shown that as few as 32% of women report symptoms to their prenatal provider, and only 25% of providers recommend treatment. Chiropractors sometimes manage low back pain in pregnant women; however, scarce data exist regarding such treatment. This retrospective case series was undertaken to describe the results of a group of pregnant women with low back pain who underwent chiropractic treatment including spinal manipulation. Seventeen cases met all inclusion criteria. The overall group average Numerical Rating Scale pain score decreased from 5.9 (range 2-10) at initial presentation to 1.5 (range 0-5) at termination of care. Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0-13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1-5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.
J Altern Complement Med. 2008 Jun;14(5):465-73.

A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic.
Wilkey A, Gregory M, Byfield D, McCarthy PW.

Private Practice, Oldham, United Kingdom.

Comment in:

J Altern Complement Med. 2008 Jun;14(5):451-2.

Abstract
OBJECTIVES: To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor.

DESIGN: The study was a pragmatic, randomized, controlled trial.

SETTING: The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom.

SUBJECTS AND INTERVENTIONS: Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting.

OUTCOME MEASURES: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student's t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated.

RESULTS: Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). Conclusions: This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.
Chiropr Osteopat. 2008 Jun 18;16:6.

The Nordic maintenance care program--case management of chiropractic patients with low back pain: a survey of Swedish chiropractors.
Axén I, Rosenbaum A, Eklund A, Halasz L, Jørgensen K, Lövgren PW, Lange F, Leboeuf-Yde C.

Karolinska Institute, Stockholm, Sweden. [email protected]

Abstract
BACKGROUND: Chiropractic treatment for low back pain (LBP) can often be divided into two phases: Initial treatment of the problem to attempt to remove pain and bring it back into its pre-clinical or maximum improvement status, and "maintenance care", during which it is attempted to maintain this status. Although the use of chiropractic maintenance care has been described and discussed in the literature, there is no information as to its precise indications. The objective of this study is to investigate if there is agreement among Swedish chiropractors on the overall patient management for various types of LBP-scenarios, with a special emphasis on maintenance care.

METHOD: The design was a mailed questionnaire survey. Members of the Swedish Chiropractors' Association, who were participants in previous practice-based research, were sent a closed-end questionnaire consisting of nine case scenarios and six clinical management alternatives and the possibility to create one's own alternative, resulting in a "nine-by-seven" table. The research team defined its own pre hoc choice of "clinically logical" answers based on the team's clinical experience. The frequency of findings was compared to the suggestions of the research team.

RESULTS: Replies were received from 59 (60%) of the 99 persons who were invited to take part in the study. A pattern of self-reported clinical management strategies emerged, largely corresponding to the "clinically logical" answers suggested by the research team. In general, patients of concern would be referred out for a second opinion, cases with early recovery and without a history of previous low back pain would be quickly closed, and cases with quick recovery and a history of recurring events would be considered for maintenance care. However, also other management patterns were noted, in particular in the direction of maintenance care.

CONCLUSION: To a reasonable extent, Swedish chiropractors participating in this survey appear to agree on the clinical management for different cases of LBP.
J Chiropr Med. 2008 Jun;7(2):59-65.

Effects of Biofreeze and chiropractic adjustments on acute low back pain: a pilot study.
Zhang J, Enix D, Snyder B, Giggey K, Tepe R.

Associate Director of Research, Logan College of Chiropractic, Chesterfield, MO 63017.

Abstract
OBJECTIVE: This randomized controlled study was designed to determine the pain-relieving effect of Biofreeze (Performance Health Inc., Export, PA) body surface application and chiropractic adjustments on subjects with acute low back pain (LBP).

METHODS: The data were collected at the baseline, 2 weeks after treatment, and 4 weeks after treatment for final analyses. Diversified manual adjustments were provided by licensed chiropractors twice a week for 4 weeks to both control and experimental groups. Biofreeze was applied to the lower back area 3 times a day for 4 weeks in the experimental group. Outcome assessments included visual analog scale, Roland Morris Disability Questionnaire, heart rate variability for stress, and electromyography for low back muscle activity.

RESULTS: A total of 36 subjects were recruited in the study (25 male). The average age was 34 years. Significant pain reduction was found after each week of treatment in the experimental group (P < .05). The Roland Morris Disability Questionnaire did not show significant changes in both groups. There were no significant differences for pain reduction in the control group. Heart rate variability analysis showed no significant change (P > .05) in the experimental group after 4 weeks of Biofreeze and chiropractic adjustments. There were no statistically significant changes in the electromyography readings between the 2 groups.

CONCLUSION: Biofreeze combined with chiropractic adjustment showed significant reduction in LBP.

Man Ther. 2009 Feb;14(1):88-100. Epub 2008 Mar 7.

Primary care clinicians use variable methods to assess acute nonspecific low back pain and usually focus on impairments.
Kent PM, Keating JL, Taylor NF.

Monash Department of Clinical Epidemiology at Cabrini Hospital, Victoria, Australia. [email protected]

Abstract
This study investigated the assessment of acute (<12 weeks duration) nonspecific low back pain (NSLBP) by primary care clinicians. The aims were to determine the methods used, whether methods differ across professional disciplines, and the extent to which clinicians assess across domains of health. Survey data were gathered from 651 primary care clinicians from six professional disciplines (Physiotherapy, Manipulative Physiotherapy, Chiropractic, Osteopathy, General Medicine, and Musculoskeletal Medicine). Descriptive statistics (proportions and frequency of use distributions) were used to describe assessment technique use, Mann-Whitney U tests were used to determine between-discipline differences in the use of each assessment technique, and Bonferroni-adjusted inferential confidence intervals were constructed to allow visual comparison of the use of assessment techniques from five health domains. The results indicate that the methods used by different professional disciplines to assess NSLBP vary considerably, as 44 out of 48 assessment techniques showed significantly different utilisation rates across professions. Furthermore, assessment across domains of health in this condition was variable, as clinicians commonly assess physical impairments and pain and less commonly assess activity limitation and psychosocial function (100% of clinicians very frequently or often assess physical impairment, 99% [95%CI 98-100%] assess pain, 21% [95%CI 15-27%] assess activity limitation, and 7% [95%CI 3-11%] assess psychosocial function). Adoption of greater standardisation of assessment by clinicians may require demonstration of the capacity of this standardisation to improve patient outcomes.
J Healthc Qual. 2006 Nov-Dec;28(6):32-9.

Assessment of chiropractic outcomes for low back pain and neck pain: a health plan quality incentive model.
Woodburn J, Branson R, Pavoloni G, Lin CC, Fritts M, Goertz C.

MinuteClinic, Inc., Minnepolis, MH, USA. [email protected]

Abstract
Blue Cross and Blue Shield of Minnesota conducted a quality improvement project to quantify and improve the clinical and functional outcomes of low back pain and neck pain patients in a chiropractic network. Improved outcomes were encouraged through a financial incentive for implementation of standard clinical outcome measurement tools, quarterly feedback to individual practices, and a face-to-face meeting to share best practices. Although a large database on baseline neck pain and low back pain and functional disability was generated, and clinically and statistically significant improvements in outcomes were documented, progressive improvement in outcomes over the 4-year project period was not found.

J Manipulative Physiol Ther. 2007 Feb;30(2):135-9.

Results of chiropractic treatment of lumbopelvic fixation in 44 patients admitted to an orthopedic department.
Orlin JR, Didriksen A.

Department of Orthopedics, Central Hospital of Sogn and Fjordane, Førde, Norway. [email protected]

Abstract
OBJECTIVES: The objectives of this study were to report on and evaluate the results of chiropractic care for patients with low back pain in an orthopedic department.

METHODS: The target group consisted of 44 consecutive patients who experienced sudden and painful low back pain caused by lumbar flexion and rotation without axial loading. Clinical and neurologic examinations by orthopedic surgeons revealed no pathology; in addition, skeletal radiography, computerized tomography, and magnetic resonance imaging findings were all normal. Diagnosis before hospitalization was acute sciatica in all cases. Examination by the doctor of chiropractic indicated that the patients had lumbopelvic fixation. According to preestablished inclusion and exclusion criteria, 33 patients were treated in the chiropractor's clinic, whereas 11 who could not be transported were initially treated by the chiropractor in the hospital. The mean follow-up was 2 years.

RESULTS: All but two patients returned to work. The period of sick leave among the patients was reduced by two thirds as compared with that associated with conventional medical treatment.

CONCLUSIONS: To our knowledge, this is the first report on the work of a chiropractor participating within an orthopedic department of a Norwegian hospital as initiated by the hospital and with full support of the staff. The results support the initiative of the Norwegian government to increase reference to chiropractors in treating patients with neuromusculoskeletal dysfunctions. Based on our experience, we believe that the inclusion of chiropractors within hospital orthopedic departments is feasible and provides a patient care resource that may benefit not only the patients but also the department as a whole.
J Altern Complement Med. 2006 Sep;12(7):659-68.

One-year follow-up of a randomized clinical trial comparing flexion distraction with an exercise program for chronic low-back pain.
Cambron JA, Gudavalli MR, Hedeker D, McGregor M, Jedlicka J, Keenum M, Ghanayem AJ, Patwardhan AG, Furner SE.

Department of Research, National University of Health Sciences, Lombard, IL 60148, USA. [email protected]

Abstract
OBJECTIVE: Flexion distraction is a commonly used form of chiropractic care with chiropractor utilization rates of 58%. However, no previous randomized clinical trial has assessed the effectiveness of this form of care. The objective of this investigation was to compare the pain and disability during the year after active care based on treatment group allocation (Flexion Distraction versus Exercise Program).

STUDY DESIGN: Randomized clinical trial, follow-up.

SUBJECTS: Two hundred and thirty-five (235) subjects who were previously randomized to either chiropractic care (flexion distraction) or physical therapy (exercise program) within a clinical trial.

OUTCOME MEASURES: Subjects were followed for 1 year via mailed questionnaires to assess levels of pain (Visual Analog Scale) and dysfunction (Roland Morris).

RESULTS: Study subjects had a decrease in pain and disability after intervention regardless of which group they attended (p < 0.002), however, during the year after care, subjects who received chiropractic care (flexion distraction therapy) had significantly lower pain scores than subjects who received physical therapy (exercise program) (p = 0.02).

CONCLUSIONS: In this first trial on flexion distraction care, flexion distraction was found to be more effective in reducing pain for 1 year when compared to a form of physical therapy.
Spine (Phila Pa 1976). 2006 Mar 15;31(6):611-21; discussion 622.

A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study.
Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM.

Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA. [email protected]

Abstract
STUDY DESIGN: Randomized clinical trial.

OBJECTIVES: To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.

SUMMARY OF BACKGROUND DATA: Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.

METHODS: A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.

RESULTS: Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.

CONCLUSIONS: Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.
Spine J. 2006 Mar-Apr;6(2):131-7. Epub 2006 Feb 3.

Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.
Santilli V, Beghi E, Finucci S.

Direttore Cattedra Medicina Fisica e Riabilitativa, Università di Roma La Sapienza, P.le Aldo Moro 5, Roma, Rome, 00185, Italy.

Abstract
BACKGROUND CONTEXT: Acute back pain and sciatica are major sources of disability. Many medical interventions are available, including manipulations, with conflicting results.

PURPOSE: To assess the short- and long-term effects of spinal manipulations on acute back pain and sciatica with disc protrusion.

STUDY DESIGN/SETTING: Randomized double-blind trial comparing active and simulated manipulations in rehabilitation medical centers in Rome and suburbs.

PATIENT SAMPLE: 102 ambulatory patients with at least moderate pain on a visual analog scale for local pain (VAS1) and/or radiating pain (VAS2).

OUTCOME MEASURES: Pain-free patients at end of treatment; treatment failure (proportion of patients stopping the assigned treatment for lack of effect on pain); number of days with no, mild, moderate, or severe pain; quality of life; number of days on nonsteroidal anti-inflammatory drugs; number of drug prescriptions; VAS1 and VAS2 scores; quality of life and psychosocial findings; and reduction of disc protrusion on magnetic resonance imaging.

METHODS: Manipulations or simulated manipulations were done 5 days per week by experienced chiropractors, with a number of sessions which depended on pain relief or up to a maximum of 20, using a rapid thrust technique. Patients were assessed at admission and at 15, 30, 45, 90, and 180 days. At each visit, all indicators of pain relief were used.

RESULTS: A total of 64 men and 38 women aged 19-63 years were randomized to manipulations (53) or simulated manipulations (49). Manipulations appeared more effective on the basis of the percentage of pain-free cases (local pain 28 vs. 6%; p<.005; radiating pain 55 vs. 20%; p<.0001), number of days with pain (23.6 vs. 27.4; p<.005), and number of days with moderate or severe pain (13.9 vs. 17.9; p<.05). Patients receiving manipulations had lower mean VAS1 (p<.0001) and VAS2 scores (p<.001). A significant interaction was found between therapeutic arm and time. There were no significant differences in quality of life and psychosocial scores. There were only two treatment failures (manipulation 1; simulated manipulation 1) and no adverse events.

CONCLUSIONS: Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.
J Chiropr Med. 2008 Dec;7(4):146-54.

Chiropractic management of a 47-year-old firefighter with lumbar disk extrusion.
Schwab MJ.

Private practice, Schwab Chiropractic Clinic, Eau Claire, WI 54701.

Abstract
OBJECTIVE: This case report describes the effect of exercise-based chiropractic treatment on chronic and intractable low back pain complicated by lumbar disk extrusion.

CLINICAL FEATURES: A 47-year-old male firefighter experienced chronic, unresponsive low back pain. Pre- and posttreatment outcome analysis was performed on numeric (0-10) pain scale, functional rating index, and the low back pain Oswestry data. Secondary outcome assessments included a 1-rep maximum leg press, balancing times, push-ups and sit-ups the patient performed in 60 seconds, and radiographic analysis.

INTERVENTION AND OUTCOME: The patient was treated with Pettibon manipulative and rehabilitative techniques. At 4 weeks, spinal decompression therapy was incorporated. After 12 weeks of treatment, the patient's self-reported numeric pain scale had reduced from 6 to 1. There was also overall improvement in muscular strength, balance times, self-rated functional status, low back Oswestry scores, and lumbar lordosis using pre- and posttreatment radiographic information.

CONCLUSION: Comprehensive, exercise-based chiropractic management may contribute to an improvement of physical fitness and to restoration of function, and may be a protective factor for low back injury. This case suggests promising interventions with otherwise intractable low back pain using a multimodal chiropractic approach that includes isometric strengthening, neuromuscular reeducation, and lumbar spinal decompression therapy.
J Manipulative Physiol Ther. 1998 Mar-Apr;21(3):187-96.

Treatment of symptomatic lumbar disc herniation using activator methods chiropractic technique.
Polkinghorn BS, Colloca CJ.

Abstract
OBJECTIVE: To describe a case of symptomatic lumbar disc herniation, successfully treated via chiropractic intervention using Activator Methods Chiropractic Technique.

CLINICAL FEATURES: A 26-yr-old man suffered from a chronic multisymptom complex composed of low back pain, left groin pain, left leg pain, left foot drop and associated muscle weakness with atrophy. The symptoms had persisted for more than 2 yr after an athletic injury. Magnetic resonance imaging evaluation revealed a 6-mm focal central disc protrusion with accompanying deformation of the thecal sac, consistent with the presenting symptoms. Lumbar spinal surgery had been recommended to the patient as the appropriate medical management for optimal outcome.

INTERVENTION AND OUTCOME: The patient elected to pursue chiropractic treatment in an effort to resolve his condition via conservative management. Chiropractic intervention consisted of mechanical-force, manually assisted short-lever adjusting procedures, rendered via an Activator Adjusting Instrument (AAI). The patient responded favorably and his multisymptom complex resolved within 90 days of treatment. No residuals or recurrences were noted at examination over 1 yr later.

CONCLUSION: This report suggests that chiropractic treatment of lumbar disc disorders may be effectively implemented, in certain cases, via mechanical-force, manually assisted adjusting procedures using an AAI. We speculate that the use of an AAI, combined with Activator methods, may provide definitive benefits over side-posture manipulation of the lumbar spine in treatment of resistive disc lesions, because of the lack of torsional stress imposed upon the disc during instrumental spinal adjustment. Further study should be made in this regard to determine the safest and most effective method to treat lumbar disc lesions in a chiropractic setting.
J Manipulative Physiol Ther. 2006 Feb;29(2):107-14.

Efficacy of treating low back pain and dysfunction secondary to osteoarthritis: chiropractic care compared with moist heat alone.
Beyerman KL, Palmerino MB, Zohn LE, Kane GM, Foster KA.

Community Health Institute, Winchester Hospital, Winchester, Mass 01890, USA.

Abstract
OBJECTIVE: To evaluate the efficacy of chiropractic spinal manipulation, manual flexion/distraction, and hot pack application for the treatment of low back pain from osteoarthritis (OA) compared with moist heat alone.

METHODS: Two hundred fifty-two patients with low back pain secondary to OA were randomly assigned to either the treatment group (moist hot pack plus chiropractic care) or the moist heat group subjects, which attended 20 treatment sessions over several weeks. At sessions 1, 5, 10, 15, and 20, they rated pain using a visual analog pain scale, activities of daily living using the Oswestry Low Back Pain Questionnaire, and a range of motion (ROM) using the J-Tech Dual Digital Inclinometer (JTECH Medical Model no. AA036).

RESULTS: Session I ratings indicated that the two groups were equivalent on all pain and flexion scores. The treatment group reported greater and more rapid pain reduction and greater and more rapid ROM improvement than the moist heat group. The treatment group also had greater improvements than the moist heat group in daily living activities in 4 of the 9 areas measured.

CONCLUSION: Chiropractic care combined with heat is more effective than heat alone for treating OA-based lower back pain. Pain reduction occurs more rapidly and to a greater degree, and ROM increases more rapidly and to a greater degree.
J Manipulative Physiol Ther. 2006 Jan;29(1):66-71.

Chiropractic and rehabilitative management of a patient with progressive lumbar disk injury, spondylolisthesis, and spondyloptosis.
Excoffon SG, Wallace H.

Rock Island Clinic, Palmer College of Chiropractic, Davenport, Iowa, USA. [email protected]

Comment in:

J Manipulative Physiol Ther. 2006 Oct;29(8):686; author reply 687.

Abstract
OBJECTIVE: To describe the chiropractic treatment for a patient with low back pain accompanied by sensory and motor deficits of his left leg and magnetic resonance imaging-documented lumbar spinal cord and nerve root impingement.

CLINICAL FEATURES: A 57-year-old man experienced low back pain that radiated into his left leg and subsequently produced both sensory and motor deficits of the left thigh and quadriceps followed by a similar weakness and accompanying paresthesia of the lower left leg. Onsets were sudden and occurred during sleep, after prolonged sitting or during long periods of driving. Diagnostic studies revealed a slight impingement at the L5-S1 level due to anterior displacement of the L5 vertebra and a mild protrusion of the L4 disk.

INTERVENTION AND OUTCOMES: Treatment consisted of chiropractic spinal manipulation, physical therapy modalities, and rehabilitative exercises. Outcome measurements in his case indicated that his rehabilitation was appropriate.

CONCLUSION: There is an abundance of published reports describing treatment of disk injury, low back pain, and spondylolisthesis with a variety of manipulative methods. However, this appears to be the first case reported in indexed literature of a progressive multilevel lumbar disk injury with concomitant spondylolisthesis and spondyloptosis.
Eur Spine J. 2006 Jul;15(7):1070-82. Epub 2005 Dec 8.

A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain.
Gudavalli MR, Cambron JA, McGregor M, Jedlicka J, Keenum M, Ghanayem AJ, Patwardhan AG.

Palmer College of Chiropractic, Research, Davenport, IA, USA. [email protected]

Abstract
Many clinical trials on chiropractic management of low back pain have neglected to include specific forms of care. This study compared two well-defined treatment protocols. The objective was to compare the outcome of flexion-distraction (FD) procedures performed by chiropractors with an active trunk exercise protocol (ATEP) performed by physical therapists. A randomized clinical trial study design was used. Subjects, 18 years of age and older, with a primary complaint of low back pain (>3 months) were recruited. A 100 mm visual analogue scale (VAS) for perceived pain, the Roland Morris (RM) Questionnaire for low back function, and the SF-36 for overall health status served as primary outcome measures. Subjects were randomly allocated to receive either FD or ATEP. The FD intervention consisted of the application of flexion and traction applied to specific regions in the low back, with the aid of a specially designed manipulation table. The ATEP intervention included stabilizing and flexibility exercises, the use of modalities, and cardiovascular training. A total of 235 subjects met the inclusion/exclusion criteria and signed the informed consent. Of these, 123 were randomly allocated to FD and 112 to the ATEP. Study patients perceived significantly less pain and better function after intervention, regardless of which group they were allocated to (P<0.01). Subjects randomly allocated to the flexion-distraction group had significantly greater relief from pain than those allocated to the exercise program (P=0.01). Subgroup analysis indicated that subjects categorized as chronic, with moderate to severe symptoms, improved most with the flexion-distraction protocol. Subjects categorized with recurrent pain and moderate to severe symptoms improved most with the exercise program. Patients with radiculopathy did significantly better with FD. There were no significant differences between groups on the Roland Morris and SF-36 outcome measures. Overall, flexion-distraction provided more pain relief than active exercise; however, these results varied based on stratification of patients with and without radiculopathy and with and without recurrent symptoms. The subgroup analysis provides a possible explanation for contrasting results among randomized clinical trials of chronic low back pain treatments and these results also provide guidance for future work in the treatment of chronic low back pain.
J Manipulative Physiol Ther. 2005 Oct;28(8):564-9.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.
Nelson CF, Metz RD, LaBrot T.

Health Services Research, American Specialty Health, San Diego, CA 92101, USA. [email protected]

Abstract
OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain.

DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit.

RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant.

CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.
J Manipulative Physiol Ther. 2005 Oct;28(8):555-63.

Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain.
Haas M, Sharma R, Stano M.

Center for Outcomes Studies, Western States Chiropractic College, Portland, OR 97230, USA. [email protected]

Abstract
OBJECTIVES: To identify relative provider costs, clinical outcomes, and patient satisfaction for the treatment of low back pain (LBP).

METHODS: This was a practice-based, nonrandomized, comparative study of patients self-referring to 60 doctors of chiropractic and 111 medical doctors in 51 chiropractic and 14 general practice community clinics over a 2-year period. Patients were included if they were at least 18 years old, ambulatory, and had low back pain of mechanical origin (n = 2780). Outcomes were (standardized) office costs, office costs plus referral costs for office-based care and advanced imaging, pain, functional disability, patient satisfaction, physical health, and mental health evaluated at 3 and 12 months after the start of care. Multiple regression analysis was used to correct for baseline differences between provider types.

RESULTS: Chiropractic office costs were higher for both acute and chronic patients (P < .01). When referrals were included, there were no significant differences in either group between provider types (P > .20). Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction (P < .01); clinically important differences in pain and disability improvement were found for chronic patients only.

CONCLUSIONS: Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain.
Spine (Phila Pa 1976). 2005 Oct 1;30(19):2121-8.

Satisfaction as a predictor of clinical outcomes among chiropractic and medical patients enrolled in the UCLA low back pain study.
Hurwitz EL, Morgenstern H, Yu F.

Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA 90095-1772, USA. [email protected]

Abstract
STUDY DESIGN: Observational study conducted within a randomized clinical trial.

OBJECTIVES: The objective of this study is to estimate the effects of patient satisfaction on subsequent changes in pain and disability among low back pain patients randomized to chiropractic or medical care in a managed-care practice setting.

SUMMARY OF BACKGROUND DATA: Recent studies of low back pain treatments have shown chiropractic patients to be more satisfied with their care than medical patients. However, little is known about the relation between patient satisfaction and clinical outcomes.

METHODS: A total of 681 low back pain patients presenting to three southern California healthcare clinics and screened for serious spinal pathology and contraindications were randomized to medical care with and without physical therapy, and chiropractic care with and without physical modalities, and followed for 18 months. Satisfaction with back care was measured on a 40-point scale and observed at 4 weeks following randomization. The primary outcome variables, observed between 6 weeks and 18 months of follow-up, are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire, and remission from clinically meaningful pain and disability. Perceived change in low back symptoms was a secondary outcome.

RESULTS: Greater satisfaction increased the odds of remission from clinically meaningful pain and disability at 6 weeks (adjusted odds ratio [OR] for 10-point increase in satisfaction = 1.61, 95% confidence interval [CI] = 0.99, 2.68), but not at 6, 12, or 18 months (6 months: adjusted OR = 1.05, 95% CI = 0.73, 1.52; 12 months: adjusted OR = 0.94, 95% CI = 0.67, 1.32; 18 months: adjusted OR = 1.07; 95% CI = 0.76, 1.50). Perception of improvement was greater among highly satisfied than less satisfied patients throughout the 18-month follow-up period. The estimated effects of satisfaction on clinical outcomes were similar for medical and chiropractic patients.

CONCLUSIONS: Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction.

 
 
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